Get () Prior Authorization Request Form ... - Optumrx

Filling out the ® () Prior Authorization Request Form is crucial for ensuring that patients receive the medication they need. This guide will provide you with clear, step-by-step instructions to effectively complete the form online.

Follow the steps to successfully complete the Prior Authorization Request Form.

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form and open it in your preferred editor.
2. Complete the Member Information section. Fill in the member’s name, insurance ID number, date of birth, and contact details accurately. Ensure all required fields are completed.
3. In the Provider Information section, enter the provider's name, NPI number, office phone, and address. Double-check for accuracy as this information is essential.
4. Move to the Medication Information section. Specify the medication name, strength, and determine if this is a new start for the medication by selecting 'Yes' or 'No'. Provide directions for use and dosage form as required.
5. Proceed to the Clinical Information section. Select the diagnosis applicable to the member from the provided options. If needed, list 'Other diagnosis' and include relevant ICD-9/10 codes.
6. Acknowledge the risk for patients aged 65 and over by selecting 'Yes' or 'No'. Also attest that no other drug can meet the patient's needs by making the appropriate selection.
7. Indicate any medications the patient has failed, contraindicated, or shown intolerance to by selecting the relevant medications listed.
8. Utilize the comments section for any additional information that could assist in the review process, including other diagnoses, medications tried, or any other essential notes.
9. Once all sections are filled out, save your changes. You have the option to download, print, or share the completed form as needed.

Complete your Prior Authorization Request Form online today for a seamless approval process.