Get Pro Act Prior Auth Form

Filling out the Pro Act Prior Auth Form online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form to ensure that you successfully complete it for prior authorization requests.

Follow the steps to efficiently complete the Pro Act Prior Auth Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering member information in the required fields. This includes the member's name, insurance ID number, date of birth, and contact information.
3. Provide the provider information, including the provider's name, national provider identifier (NPI), office phone, and street address.
4. Fill in the medication information. Specify the medication name, strength, and indicate if you are requesting the brand or if this is for continuation of therapy. Include the directions for use and dosage form.
5. In the clinical information section, select the relevant diagnosis from the provided options. Input the corresponding ICD-10 codes as required.
6. Answer the specific questions based on the diagnosis provided—such as previous medication failures or contraindications—and select options accordingly.
7. If the request is for reauthorization, respond to the additional questions related to symptom recurrence and previous treatment courses for the specified diagnosis.
8. For quantity limit requests, specify the number of units requested per day and provide a reason for exceeding standard limitations.
9. Finally, use the provided section to include any additional comments or important clinical information that may assist in the review process.
10. Review all information entered on the form for accuracy. Once confirmed, you can save your changes, download a copy, or print the form for submission.

Start filling out the Pro Act Prior Auth Form online today to streamline your prior authorization requests.