Get Lidocaine Patch () Prior Authorization Request Form

This guide provides clear and detailed instructions on how to complete the Lidocaine Patch (®) Prior Authorization Request Form online. By following these steps, you can ensure that your authorization request is submitted accurately and efficiently.

Follow the steps to successfully complete the authorization form.

1. Press the ‘Get Form’ button to access the form online and open it for editing.
2. Begin filling out the member information section. You will need to provide the member's name, date of birth, and insurance ID number.
3. Next, complete the provider information section. This includes the provider's name, NPI number, office phone, and fax number.
4. In the medication information section, enter the medication name as 'Lidocaine Patch' or '®', along with strength, dosage form, and check the box if you are requesting the brand.
5. Indicate the directions for use and answer if this is a continuation of therapy, providing the necessary details regarding previous use.
6. Complete the clinical information section by selecting the requested drug and applicable diagnosis.
7. Answer all clinical questions thoroughly, including information regarding medication history and reauthorization if applicable.
8. In the prescriber attestation section, verify the prescriber's signature and date to confirm the accuracy of the provided information.
9. Review all completed sections to ensure that the necessary information is filled out completely. Make any needed edits.
10. Finally, save your changes, and choose to download, print, or share the form as needed.

Submit the Lidocaine Patch Prior Authorization Request Form online to ensure timely processing.