Follow the steps to complete your request effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the patient information section, including the patient’s name, date of birth, and member ID. Make sure all entries are legible to avoid processing delays.
3. Provide the contact person's details by entering their name, office phone number, and office fax number. This information ensures that CareOregon can reach someone for follow-up.
4. Indicate the date of the original denial in the designated field. This helps in tracking the request timeframe.
5. List any additional diagnosis codes (ICD-10) that apply to the situation, ensuring accurate documentation is provided.
6. Check all applicable reasons given for the original denial. Options include age or quantity limit exceeded, experimental/investigational use, below the line diagnosis, insufficient information, does not meet PA criteria, non-formulary, or other.
7. Provide a comprehensive statement explaining why you disagree with the original denial reason and/or the criteria used, along with any supporting documentation like medical records or clinical studies.
8. The prescriber should sign and date the form in the designated areas. This signifies the prescriber's agreement and authorization for the request.
9. Once all sections are completed, save your changes and prepare to submit the form. You can download, print, or share the form as needed before faxing it to 503-416-1428.

Complete your documents online to expedite the reconsideration process.