Get Mvp Health Care Weight Loss Prior Authorization Form

Filling out the MVP Health Care Weight Loss Prior Authorization Form requires careful attention to detail to ensure all necessary information is accurately submitted. This guide will provide clear, step-by-step instructions for completing the form online.

Follow the steps to successfully complete the authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of the request in the appropriate field at the top of the form. This serves to document when the authorization is being requested.
3. Fill in the prescribing physician information, including their name and National Provider Identifier (NPI) number. Ensure that you provide accurate contact details.
4. Provide member information including their name, address, identification number, birthdate, and contact phone number. This information helps to identify the member for whom the request is being made.
5. In the 'Drug Requested' section, clearly specify the drug name, strength, and dosage required for the treatment. Remember to only input one drug per member per treatment period.
6. Enter the diagnosis information including the ICD-10 code, which classifies the member's condition for precise reference.
7. Document previous medications that have been tried and the treatment period with details about the weight loss that has been achieved in the specified months, following the required minimum loss criteria.
8. Indicate any comorbidities by documenting the required health information including blood pressure and cholesterol levels where applicable. Include the dates these measures were taken.
9. Ensure that you attest to the accuracy of the information by signing in the designated provider signature field. This confirms that the medical record is available if requested.
10. Finally, you can review all entered information, save changes, download, print, or share the completed form as needed.

Complete your forms online to ensure a smooth authorization process.