Get Empireblue Com Form

Filling out the Empireblue Com Form online is a crucial step in the prior authorization process for medical injectables. This guide will provide you with comprehensive instructions to ensure all necessary information is accurately submitted and processed efficiently.

Follow the steps to complete the Empireblue Com Form online:

1. Press the ‘Get Form’ button to access the document and open it in your preferred online editor.
2. Begin by entering the member information. Fill out the fields for last name, first name, member ID number, gender, and date of birth. Additionally, include the member's height and weight.
3. Indicate the member’s place of residence by checking the appropriate box for home, nursing facility, office, or outpatient facility.
4. Complete the prescriber information section, including last name, first name, NPI, tax ID, phone number, and fax number.
5. Provide the address where services were rendered, including the city, state, ZIP code, and office contact name, along with their direct phone number.
6. If the service location address is not the same as the billing address, answer ‘No’ and enter the required billing facility information, including the facility name, NPI, DEA, and contact person's details.
7. In the medication information section, record the drug name, strength requested, SIG (dose, frequency, duration), diagnosis, HCPCS billing code, and ICD code.
8. Indicate whether the member has tried other medications for this condition. If yes, provide the required information, including details of any adverse reactions or inadequate responses.
9. Describe the medical necessity for non-preferred medications or using prescriptions outside of FDA labeling.
10. List all current medications, including their doses and frequency, along with any other pertinent information.
11. Document any diagnostic studies or laboratory tests that have been performed related to the diagnosis or medication requested.
12. Finally, certify the information provided by signing and dating at the designated area before submitting the form.
13. After completing the form, users can save the changes, download, print, or share the form as needed.

Complete your Empireblue Com Form online today to ensure a smooth prior authorization process.