Get 855 240 0536

Filling out the 855 240 0536 form online is a crucial step in ensuring that the necessary prior authorization for medications is obtained. This guide provides a clear, step-by-step approach to help you navigate through each section of the form seamlessly.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the form and open it in your browser.
2. Begin by filling out the patient information section. Enter the patient’s name, ID number, address, city, state, and zip code. Also, include their home phone number and gender.
3. Next, provide the prescriber's information. This includes the prescriber’s name, address, city, state, zip code, office phone number, and fax number.
4. Continue with the diagnosis and medical information section. Fill in the strength, medication, expected length of therapy, diagnosis, quantity, day supply, and frequency.
5. Indicate if this request is for a continuation of therapy by specifying how long the patient has been on the medication and entering the diagnosis (ICD) code(s).
6. You will need to check all relevant boxes regarding the patient's medical history and other prescribed medications. Detail any prior medications the patient has tried along with reasons for their failure.
7. Fill in the information regarding any contraindications or adverse events associated with previous medications and elaborate on chronic conditions if applicable.
8. In the last section, confirm the medical necessity of the prescribed medication. The prescriber should sign and date the form, asserting that the provided information is accurate.
9. Review the completed form for accuracy. After verifying all entries, you can save the changes, download a copy, or share the form as needed.

Complete the 855 240 0536 form online today to ensure timely medication authorization.