Get Multiple Sclerosis Crd Prior Authorization Form. Prior Authorization Form For Multiple Sclerosis.

Completing the Multiple Sclerosis CRD Prior Authorization Form can be straightforward with the right guidance. This guide provides detailed instructions to assist users in navigating each section of the form efficiently and accurately.

Follow the steps to successfully complete the Multiple Sclerosis CRD Prior Authorization Form.

1. Click ‘Get Form’ button to access the Multiple Sclerosis CRD Prior Authorization Form in an editable format.
2. Fill in the physician information section, including the physician's name, specialty, and their DEA, NPI, or TIN. Ensure to provide an office contact person and office phone number.
3. Complete the patient information section. Fill in the patient's name, Cigna ID, street address, city, state, zip, date of birth, and patient phone number. Pay special attention to filling out all fields marked with an asterisk (*), as these are necessary for the review process.
4. Indicate the urgency of the request by selecting either 'Standard' or 'Urgent.' If 'Urgent' is selected, confirm the statement that applying the standard review time may jeopardize the patient’s health.
5. Specify the medication requested from the list provided, including dosage and quantity. If applicable, include the duration of therapy and frequency of administration.
6. Indicate whether this is a new start or a continuation of therapy, providing the necessary details based on the patient's previous treatment history.
7. Provide information about where the medication will be obtained, including the pharmacy type and facility details if applicable.
8. Complete the diagnosis and any relevant clinical information, documenting previous medications tried and responses to them as required.
9. If applicable, provide details on any intolerances or contraindications regarding other medications mentioned in the form. Ensure all reasons are documented accurately.
10. Fill in the additional comments or clinical rationale at the end of the form if needed.
11. Once all information is filled in and verified, save changes, print, and/or share the form as needed. For submission, fax the completed form to (855) 840-1678.

Complete your Multiple Sclerosis CRD Prior Authorization Form online to ensure a smoother approval process.