Get Flector Prior Authorization Request Form (page 1 Of 2)

This guide provides a comprehensive overview of how to fill out the Flector Prior Authorization Request Form online. By following these steps, you can ensure that all necessary information is accurately submitted to facilitate a smooth authorization process.

Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to obtain the Flector Prior Authorization Request Form and open it in your preferred online editor.
2. Enter the member information in the designated fields. This includes the member's name, insurance ID number, date of birth, and contact information. Ensure accuracy as this information is essential for processing the request.
3. Provide the provider information, including the provider's name, NPI number, office phone, and fax number. Include the office's street address, city, state, and zip code.
4. Under the medication information section, fill out the medication name, strength, and indicate if you are requesting the brand or if the request is for a continuation of therapy. Specify the directions for use and dosage form as well.
5. In the clinical information section, select the applicable diagnosis and enter the corresponding ICD-10 codes. Answer the questions regarding the use of the requested medication for localized pain and other specified conditions.
6. Indicate any treatment failures with other medications listed and provide details for any quantity limit requests, including the reason for exceeding plan limitations if applicable.
7. Review all the information entered for accuracy. Make sure all required sections are completed before saving the form.
8. Once all information is verified, you can download, print, or share the completed form as needed.

Complete the Flector Prior Authorization Request Form online today to ensure timely processing of your request.