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

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form and open it in your editing software.
2. Complete the provider information section with your name, National Provider Identifier (NPI) number, and contact details including address, phone number, and fax number.
3. Fill in the member information section with the patient's name, ID number, birthdate, and relevant contact details.
4. Select the drug requested from the provided options, indicating whether it is for initial therapy or a continuation of therapy.
5. Specify the dosage, frequency, and duration of the therapy as applicable to the patient's treatment plan.
6. Provide the diagnosis and the appropriate ICD-9 code to ensure correct processing of the request.
7. Answer the questions regarding swollen or tender joints, morning stiffness, and any history of severe or chronic infections, checking the appropriate boxes.
8. List any current and past therapies along with their dosages and responses, providing thorough documentation to support the request.
9. For ankylosing spondylitis, complete the specific measurements as indicated in the form.
10. Review the entire form for accuracy and completeness, ensuring that all required documentation is included.
11. Once everything is filled out, save your changes, download a copy of the form, and print or share as needed.

Complete your prior authorization requests online for better efficiency and a smoother process.