Follow the steps to accurately fill out the Prior Authorization Request Form.

1. Press the 'Get Form' button to obtain the form and open it in your preferred editor.
2. Fill out the member information section. Make sure to complete all required fields, including today's date, member's name, ID number, date of birth, and contact details.
3. In the prescriber information section, enter the prescriber's name, specialty, NPI or DEA number, and contact information. Ensure that all fields marked with an asterisk are completed.
4. Provide the drug information. Only one drug request is allowed per form, so fill out the drug name, dosage form, strength, directions for use, therapy start date, and therapy end date.
5. Complete the diagnosis section by entering the ICD10 code and a description of the diagnosis, along with the date of diagnosis. Remember to attach any relevant diagnostic clinicals.
6. In the medication history section, answer the questions regarding the member's current medication status and previous treatments. Fill out details for any previous medications and their outcomes.
7. Provide the rationale for the request and any pertinent clinical information. Ensure to support your request with adequate clinical detail, attaching additional sheets if necessary.
8. Sign the form in the designated areas, indicating whether to dispense as written or if substitution is permitted, along with the dates for each signature.
9. Review the entire form for accuracy. Once confirmed, save changes, download, print, or share the completed form as needed.

Ensure your medication is approved by completing the Prior Authorization Request Form online today!