Get Synapryn

Filling out the Synapryn prior authorization request form is essential for obtaining coverage for certain medications. This guide provides comprehensive, step-by-step instructions to assist users in completing the form accurately and efficiently, ensuring all necessary information is submitted.

Follow the steps to complete the Synapryn prior authorization request form online.

1. Click the ‘Get Form’ button to access the Synapryn form and open it in your preferred editor.
2. Provide the required member information, including the member's name, date of birth, insurance ID number, and street address.
3. Complete the provider information section by entering the provider's name, NPI number, office phone number, and fax number.
4. In the medication information section, list the medication name, strength, indicate if you are requesting the brand, and provide directions for use and dosage form.
5. Answer the clinical information questions, ensuring you provide accurate responses regarding the member's condition, prior medications, and any required medical records.
6. For specific conditions, fill out the additional questions regarding terminal illnesses or non-terminal conditions as applicable.
7. Complete the prescriber attestation section by signing and dating the form, confirming that the information is accurate to the best of your knowledge.
8. Review all sections to ensure accuracy and completeness, then save your changes.
9. Finally, you can choose to download, print, or share the completed form as needed.

Complete your Synapryn prior authorization request online today!