Get 470-4119 Request For Prior Authorization Selected Brand Name Drugs - Dhs Iowa

Completing the 470-4119 Request For Prior Authorization Selected Brand Name Drugs form is essential for users seeking prior authorization for specific medications. This guide provides clear, step-by-step instructions to help you fill out the form online with confidence.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the 470-4119 form and open it in your document editor.
2. Fill in the patient information section, including the patient's name, sex, Medicaid ID, date of birth, weight, and phone number. Indicate whether a generic medication has been tried before, and if so, provide the date and age at the time.
3. In the adverse event or contraindication section, detail any adverse reactions or treatment failures. Check all applicable outcomes attributable to the adverse event and provide relevant dates.
4. Describe the adverse event or problem thoroughly and provide relevant medical history and tests taken that relate to the incident.
5. Indicate the degree of certainty regarding the relationship of the adverse drug reaction to the generic medication, selecting from categories ranging from definite to negative.
6. List any concomitant medications the patient is currently taking in the suspect medications section, specifying the medication names, strengths, and manufacturers where known.
7. In the reporter certification section, the prescriber should sign and verify that the brand medication is medically necessary, along with their name, address, and NPI number.
8. Complete the remaining information regarding therapy dates, diagnosis for use, lot and NDC numbers if known, and whether the adverse reaction was witnessed by the prescriber.
9. Review all provided information to ensure accuracy and completeness, as incomplete forms will be returned.
10. Once the form is filled out, save changes, and choose to download, print, or share the completed document as necessary.

Start filling out your 470-4119 form online today to ensure timely authorization for your needed medications.