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Filling out the prior authorization form for multiple sclerosis therapy can be an essential step in securing coverage for necessary medications. This guide provides a clear, step-by-step process to ensure that users can accurately complete the form online.

Follow the steps to successfully submit your form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the 'Plan member information' section. Fill in your contract number and member ID number. Provide your last name, first name, and your address, including apartment or suite number, city, province, postal code, and daytime phone number. Select your preferred language of correspondence.
3. Provide your date of birth in the specified format (dd-mm-yyyy), and if applicable, include the fax number. Next, complete the 'Claimant information' section by entering the claimant's last name, first name, and date of birth.
4. Indicate the relationship to the plan member by selecting from the options provided (self, spouse, child). Review the 'Authorization and signature' section, where you will verify the accuracy of the information you have provided.
5. Sign the form in the space provided and date it appropriately (dd-mm-yyyy).
6. Proceed to the 'To be completed by prescribing physician' section. Ensure the prescribing physician fills out their information, including last name, first name, specialty, and their contact details.
7. Instruct the physician to complete the drug name (), strength, and dosage. The physician must confirm whether the criteria for reimbursement are met by checking the relevant box.
8. Include any additional relevant information as required and ensure the physician signs and dates the form.
9. Once all sections are complete, review the entire form for accuracy. You can then save changes, download the completed form, print it for your records, or share the form as needed.

Begin the process of obtaining your prior authorization by completing the form online today.