Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the 'Date of Request' field with the current date to indicate when the request is being submitted.
3. Enter the 'Patient Information,' including the patient's name, member ID number, date of birth, sex (select either Male or Female), and contact information such as their phone number.
4. Provide 'Prescriber Information' which includes the prescriber’s name and specialty, their office phone number, office fax number, and their National Provider Identifier (NPI) number.
5. In the 'Diagnosis and Medical Information' section, fill in details regarding the medication such as the name, strength, route of administration, frequency, quantity, height and weight of the patient, body mass index (BMI), and expected length of therapy.
6. Document the blood pressure reading under 'Blood Pressure' and the date it was taken.
7. State the diagnosis that is related to the medication request under 'Diagnosis Related to Medication Request' and list any drug allergies that the patient has.
8. In the 'Rationale for Prior Authorization' section, provide a history of the medical condition, allergies, or any other pertinent information that justifies the request for the medication.
9. List any previous use of non-authorized or prior authorized medications that were tried and failed for this condition. For each medication, include the name, reason for failure, and the date of failure.
10. Attach the most recent relative laboratory results to ensure a complete prior authorization review.
11. Ensure that the prescriber signs and dates the form at the designated 'Prescriber’s Signature' section.
12. Once all fields are completed and legible, save your changes. You may then download, print, or share the completed form as necessary.

Complete your MI Meridian Medication Prior Authorization Request online today!