Follow the steps to accurately complete the form for online submission.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the patient’s name in the designated field.
3. Fill in the prescriber’s name and fax number to ensure the request can be processed.
4. Provide the member or subscriber number associated with the patient’s insurance.
5. Input the patient’s phone number for any necessary follow-up communications.
6. Specify the patient’s date of birth to confirm their identity.
7. Enter the office contact's name and the tax identification number.
8. Fill in the group number associated with the patient’s health plan.
9. Input the prescriber’s National Provider Identifier (NPI) number.
10. Provide the address, including city, state, and ZIP code for both the prescriber and the patient.
11. If applicable, enter the specialty or facility name related to the request.
12. Indicate whether you are giving notification or requesting advanced coverage determination.
13. If an expedited review is required, check the appropriate box and provide an explanation.
14. Fill out the drug name and strength, along with the dosage per infusion or injection.
15. Specify the number of infusions or injections and the quantity/units required.
16. Include the frequency of administration and the anticipated date of service.
17. Attach any relevant medical history or information that may support the request.
18. Complete the diagnosis and provide any relevant coding information, such as J-Codes or ICD diagnostic codes.
19. Indicate whether the drug will be administered by an infusion pump and provide necessary details if it is.
20. Conclude by providing the prescriber’s signature and date, certifying the information is accurate.

Complete the Humana Medical Precertification Request Form online today for a smooth submission process.