Get 2018 Asuris Northwest Health Pre-authorization Request Form

Completing the 2018 Asuris Northwest Health Pre-Authorization Request Form online is an essential step in obtaining necessary prescription drug benefits. This guide will provide you with detailed instructions to ensure a smooth and accurate completion of the form.

Follow the steps to effectively fill out the form.

1. Press the ‘Get Form’ button to access the 2018 Asuris Northwest Health Pre-Authorization Request Form and open it in your preferred editor.
2. Begin by entering the date in the relevant field. Ensure that this reflects the date you are submitting the request.
3. Fill in the claimant's name and date of birth accurately to identify the individual requesting benefits.
4. Provide the claimant's address, ensuring complete and accurate information to facilitate communication.
5. Indicate the date of injury, the employer's name, and the claim number to offer context to the request.
6. Specify if the claimant is a first responder by selecting 'Yes' or 'No'.
7. In the 'Requesting Provider or Facility' section, include the name, phone number, fax number, NPI number, Tax ID, and address of the provider or facility.
8. List the ordering physician’s name, NPI, Tax ID, and contact details for clear communication.
9. Provide the place of service along with the physician's name, NPI, and Tax ID numbers in the appropriate fields.
10. In the 'Prescription Drug Information' section, enter the requested drug name, strength, route of administration, quantity, and expected therapy duration. Clearly specify if it is a new therapy or a continuation.
11. For provider-administered drugs, include the HCPCS code, NDC number, and dose per administration.
12. If applicable, fill in the 'Prescription Device Information' section with the requested device name and expected duration of use.
13. In 'Patient Clinical Information', detail the patient's diagnosis, ICD code, and any relevant prior treatments, allergies, and laboratory values.
14. Ensure to attach any necessary clinical documentation and physician signed orders to support the request.
15. Once all fields are completed, review the form for accuracy, save changes, and prepare to fax the completed form to 888-777-8272.

Start completing your 2018 Asuris Northwest Health Pre-Authorization Request Form online today!