Get Prior Authorization Criteria Form - Intotal Health

This guide aims to assist users in accurately completing the Prior Authorization Criteria Form for INTotal Health online. By following these detailed steps, you can ensure that all necessary information is provided to facilitate the approval process.

Follow the steps to effectively complete the form.

1. Click the ‘Get Form’ button to access the Prior Authorization Criteria Form and open it in your preferred editing tool.
2. Enter the patient's information in the specified fields, including their name, ID, group number, date of birth, and phone number.
3. Provide the prescribing physician's details, including their name, phone number, fax number, address, and city, state, and zip code.
4. Indicate the diagnosis and corresponding ICD code relevant to the patient's condition.
5. Fill out the medication details. Specify the drug name, quantity, frequency, route of administration, strength, and the expected length of therapy.
6. Respond to all questions in the comments section by circling 'Yes' or 'No' as applicable. Make sure to include any necessary documentation where indicated.
7. Ensure the prescriber signs and dates the form, affirming the accuracy of the information provided.
8. Once the form is completed, save the changes, then download, print, or share the form as needed.

Complete your Prior Authorization Criteria Form online today for efficient processing.