Follow the steps to accurately complete the prior authorization form.

1. Press the ‘Get Form’ button to access the Cigna IVIG-SCIG PSP Prior Authorization Form and open it for editing.
2. Begin by filling out the Physician Information section. Include details like physician name, specialty, and DEA, NPI or TIN. Ensure that all asterisked (*) items are completed for privacy regulations.
3. Proceed to the Patient Information section. Enter the patient’s name, date of birth, Cigna ID, address, and phone number. Completing this section accurately is crucial for timely processing.
4. Specify the urgency of the request by selecting either 'Standard' or 'Urgent.' If you select 'Urgent,' you are certifying that applying the standard review time may jeopardize the patient’s health.
5. Detail the medication requested. Indicate whether it is Intravenous or Subcutaneous, and list the specific medication from the provided options. Include the J-Code and ICD10 if applicable.
6. Indicate the requested dose and frequency. Be specific about the amount in grams, days, and weeks. Provide the patient’s current weight and the duration of the therapy.
7. Select the location where the medication will be obtained and administered. Specify whether it will be from Accredo Specialty Pharmacy, a physician’s office, or another location.
8. Complete the Diagnosis section, ensuring to provide relevant information about the condition being treated. This section may require detailed documentation to support the diagnosis.
9. Fill out any additional sections pertaining to diagnosis groups, providing information as needed. Ensure that all required documentation is attached if necessary.
10. Review the Attestation section, confirming that the information provided is accurate. Ensure the prescriber signs and dates the form.
11. Once completed, save the changes to your document. You can choose to download, print, or share the filled-out form, as required.

Submit your forms online to streamline your prior authorization process.