Get Evicore Healthcare Medical Drugs Prior Authorization Form

This guide provides a step-by-step approach to completing the EviCore Healthcare Medical Drugs Prior Authorization Form online. By following these instructions, you will be able to successfully navigate the form and ensure accurate submission for medical drug authorization.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient information section, including the member identification number, name, subscriber number, address, date of birth, phone number, and authorized representative information.
3. In the requesting provider information section, provide the provider NPI number, address, phone number, tax ID number, fax number, DEA number (if required), office contact person, specialty, and office contact fax and phone numbers.
4. Next, complete the medication information section by entering the medication name and strength, directions for use, indicating if this is a new therapy or a renewal, duration of the treatment, and the quantity requested.
5. Include the relevant HCPC or CPT codes and specify the location of administration by checking the corresponding box, such as physician’s office, infusion center, or patient home.
6. Detail the diagnosis and method of administration, checking the appropriate options for oral, topical, injection, IV, or other methods.
7. List any relevant medications that have been tried and failed, as well as the corresponding provider name.
8. If applicable, fill in the servicing provider information if it differs from the requesting provider. Include their tax ID number, address, fax number, and phone number.
9. Attach any relevant clinical information that supports the request for prior authorization.
10. Finally, complete the attestation section by providing your signature and date, confirming the truthfulness of the provided information.
11. Once all fields are completed, you can save the changes, download the form, print it, or share it as necessary.

Start completing your EviCore Healthcare Medical Drugs Prior Authorization Form online today.