Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the LA Healthcare Connections Prior Authorization Form and open it in your preferred editing tool.
2. Begin by providing the patient's information. Fill in the patient’s name, address, city, state, zip code, and contact numbers, including home and alternate phone numbers. Ensure the date of birth and gender are accurately recorded.
3. If the medication needs to be shipped to a different location, complete the other shipping location information section with the name, address, phone, fax, and contact name.
4. Next, fill out the prescriber information. Include the prescriber's name, specialty, NPI number, and the group or hospital they are associated with. Also, provide the prescriber’s address, city, state, zip code, and contact numbers.
5. In the insurance information section, list the primary and secondary insurance details. Fill in the insurance name, policy ID, and contact phone number for both insurance providers.
6. Complete the statement of medical necessity. Detail the diagnosis, including the ICD9 code and a description. Additionally, provide the date of diagnosis and any supporting documentation such as clinical labs or examinations.
7. Indicate whether the member is currently treated with the requested medication, how long treatment has been ongoing, and whether the request is a continuation of a previous approval.
8. Fill out the section on medications requested by providing the medication name, strength, dosage, directions, quantity, refills, and the therapy start date. Ensure your information is precise.
9. Finally, secure the prescriber’s signature and date the form. Review the entire form for completeness and accuracy.
10. Save any changes to the form. You can then download, print, or share the completed form as needed.

Start filling out your LA Healthcare Connections Prior Authorization Form online today!