Get Prior Authorization Request Form ... - Optumrx

Filling out the Prior Authorization Request Form is an essential step in ensuring that necessary medications are covered under a patient’s benefit plan. This guide provides a clear, step-by-step approach to assist users in accurately completing the form online, helping facilitate timely approval and access to the required medications.

Follow the steps to complete the Prior Authorization Request Form effectively.

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form. This will allow you to obtain the necessary document and start your submission process.
2. Fill in the member information section. You will need to provide the member's name, date of birth, and insurance ID number, along with their current street address, city, state, and zip code.
3. Complete the provider information section. Include the provider's name, NPI number, office phone, and fax number, as well as the office street address.
4. Proceed to the medication information section. Specify the medication name, select if you are requesting the brand, and fill in the strength and dosage form, as well as directions for use.
5. Next, fill in the clinical information. Answer the questions regarding the patient's current medications, therapy continuation, and any previous medications tried or failed.
6. Indicate the diagnosis for the medication being requested, including the relevant ICD-10 code(s). Document any medications related to failures or intolerances, along with their trial dates.
7. Complete the prescriber attestation by confirming the accuracy of the information and signing the form. Input the date of signature as well.
8. Review all completed sections for accuracy and completeness. Once confirmed, you can save the changes, download the form, print it for physical submission, or share it as needed.

Start filling out the Prior Authorization Request Form online to ensure timely processing of medication requests.