Get Sustained-release (sr) Prior ... - Optumrx

Completing the Sustained-release (SR) Prior Authorization Request Form is an essential step in ensuring that the medication is covered for the member. This guide provides clear, step-by-step instructions for filling out this form online, making the process efficient and straightforward.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Sustained-release (SR) Prior Authorization Request Form, ensuring you have the most recent version.
2. Begin by entering the member information. Fill in the required fields such as member name, insurance ID number, and date of birth.
3. Next, provide the provider information, including the provider's name, NPI number, office phone, and address.
4. In the medication information section, indicate the medication name, strength, and dosage form. Check the box if requesting the brand version.
5. Answer whether this is a continuation of therapy by selecting ‘Yes’ or ‘No.’ If ‘Yes,’ complete the follow-up questions regarding previous medication usage and its effectiveness.
6. Fill out the clinical information section. Select the requested drug from the available options and specify the diagnosis.
7. Answer additional questions regarding any ongoing treatments or counseling related to tobacco cessation.
8. If applicable, provide reauthorization details to confirm the continuation of therapy and any related treatments.
9. Ensure the prescriber attests to the accuracy of the information by signing and dating the form.
10. Review the entire form for completeness, then save changes, download, or prepare to print and fax the completed form to the designated number.

Complete your Sustained-release (SR) Prior Authorization Request Form online for efficient processing.