Get Spravato Crd Prior Authorization Form. Prior Authorization Form For Spravato.

Completing the Spravato CRD Prior Authorization Form is a crucial step in securing medication for individuals in need of treatment-resistant depression. This guide will help you navigate the form with ease and accuracy.

Follow the steps to effectively fill out the form.

1. Click 'Get Form' button to access the Spravato CRD Prior Authorization Form and open it for editing.
2. Provide the physician information in the designated fields, including the physician's name, specialty, and their DEA, NPI or TIN.
3. Fill out the patient information section. Ensure that all items marked with an asterisk (*) are completed, as this is vital for privacy regulations. Include the patient's name, contact numbers, Cigna ID, street address, date of birth, and medical state/city/zip.
4. Indicate the urgency of the request by selecting either 'Standard' or 'Urgent'. If urgent, confirm that this may jeopardize the patient's life or health.
5. In the medication requested field, select the appropriate option for the Spravato dosage and provide directions for use.
6. Enter the ICD-10 code, the quantity needed, and the duration of therapy.
7. Specify whether this is a new start or continuation of therapy and include the start date if applicable. For continued therapy, note any documented improvement in depression rating scale scores.
8. Detail where the medication will be obtained, choosing from retail pharmacy, home health, or prescriber’s office stock.
9. Answer questions about home infusion eligibility, chronic conditions, and the patient's diagnosis, providing relevant documentation as needed.
10. Review clinical information questions carefully, providing thorough and accurate responses to ensure supportive documentation is attached.
11. Complete the attestation statement and have the prescriber sign and date the form.
12. Once all required fields are filled out correctly, save changes and download the completed form. You can also print or share it as needed.

Complete the Spravato CRD Prior Authorization Form online today to support effective treatment for yourself or a loved one.