Get Department Of Health Services Division Of Health Care Access And Accountability F-00583 (0312)

Filling out the DEPARTMENT OF HEALTH SERVICES Division Of Health Care Access And Accountability F-00583 (0312) form online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form to ensure you provide all necessary information accurately.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by filling out Section I, which includes the member's information. Provide the member's full name, identification number, and date of birth.
3. Proceed to Section II, where you will enter prescription information. Fill in the drug name, strength, date the prescription was written, number of refills, and directions for use.
4. Continue by providing the prescriber's details, including their name, National Provider Identifier, address, and telephone number in Section II.
5. For initial prior authorization requests, fill out Section III with the clinical information, including diagnosis code, hepatitis C genotype, age status, pregnancy status, and treatment history.
6. If applicable, provide additional clinical justification for prescribing specific drugs in Section IIIA for Olysio requests.
7. For renewal prior authorization requests, complete Section IV or Section V as required, entering HCV-RNA levels and dates measured.
8. Ensure you sign and date Section VI with the prescriber’s signature before submitting.
9. If there is additional information relevant to the case, include it in Section VII.
10. After completing the form, save any changes, then download, print, or share the completed form as necessary for submission.

Complete your forms online efficiently and ensure timely processing.