Get Wi Dhs F-01950 2021-2026

The WI DHS F-01950 form, also known as the prior authorization drug attachment for cytokine and cell adhesion molecule antagonist drugs for Crohn’s disease and ulcerative colitis, is essential for healthcare providers seeking prior authorization for specific medications. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently online.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to access the form and open it in your chosen online editor.
2. Begin filling out Section I by providing the member's information. Enter the member's full name, member ID number, and date of birth accurately in the designated fields.
3. Proceed to Section II, which involves prescription information. Clearly enter the drug name, drug strength, date the prescription was written, directions for use, prescriber’s name, national provider identifier, address, and phone number.
4. In Section III A, provide clinical information for Crohn’s disease and ulcerative colitis. Input the diagnosis code and description, ensuring to answer the yes or no questions regarding the member’s conditions and prior medication attempts. Be thorough, as a copy of the member’s medical records must accompany the submission.
5. For Section III B, if applicable, include the clinical justification for prescribing XR over , detailing why it is necessary for the member.
6. Complete Section IV by obtaining the prescriber’s signature and date. This section must be signed to validate the authorization request.
7. Finally, utilize Section V to add any additional information that may support the request. This could include diagnostics or further explanations of the need for the requested products.
8. Once all fields are carefully filled out, ensure to save your changes, download a copy of the completed form, print it for your records, or share it as needed.

Start filling out the WI DHS F-01950 form online to facilitate the prior authorization process.