Get 61 211

Filling out the 61 211 form is an essential step in requesting prior authorization or a step therapy exception for prescription drugs. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the 61 211 form online.

1. Press the ‘Get Form’ button to access the 61 211 form and open it on your device.
2. Begin by completing the patient information section. Fill in the patient's first name, last name, middle initial, address, phone number, city, state, and zip code. Provide the date of birth and select the gender.
3. Next, complete the allergies section, noting any known allergies. If there is a patient’s authorized representative, provide their information, including their phone number.
4. Move on to the insurance information section. List the primary and secondary insurance names along with the corresponding patient ID numbers.
5. Fill in the prescriber information, including their first name, last name, address, specialty, NPI number, DEA number (if required), phone number, fax number, and email address.
6. In the medication and medical information section, specify the medication name, whether it is a new therapy or a renewal, and indicate if it is a step therapy exception request. Include the date therapy was initiated, duration of therapy, dosage, frequency, and administration details.
7. Provide information on previous medications tried for the condition, including specific medication names, dosages, duration, and reasons for failure or allergies.
8. List the patient's diagnoses using the appropriate ICD-10 codes, and provide all relevant clinical information that supports the authorization request.
9. Attach any necessary documentation, such as lab results or chart notes, that may aid in the review process.
10. Finally, review the attestation statement, sign as the prescriber or provide electronic identification verification, and date the form. Save your changes, and you will have the option to download, print, or share the completed form.

Complete your documents online today to ensure a smooth authorization process.