Get Wi Dhs F-01247 2020-2026

The WI DHS F-01247 form is essential for submitting a prior authorization request for hepatitis C agents in Wisconsin. This guide provides clear, step-by-step instructions for completing the form online to ensure a smooth submission process.

Follow the steps to fill out the WI DHS F-01247 form online effectively.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. In Section I, input the member's information, including their name (last, first, middle initial) and member ID number. Additionally, provide the member's date of birth.
3. Move to Section II and fill out the prescription information. Enter the date the prescription was written, the prescriber's name, national provider identifier, address, and phone number.
4. Indicate the member’s proposed hepatitis C drug treatment regimen. For each drug, specify if the member is currently taking it, along with the daily dose and expected duration.
5. Section III requires clinical information. Fill in the diagnosis code and description. Ensure to upload relevant medical records that include a hepatitis C virus assessment, treatment plan, and lab tests.
6. Specify if there is a clinically significant drug interaction by answering yes or no and providing details if applicable.
7. Indicate any medical conditions that prevent the use of preferred drugs by listing those conditions and their impact on drug use.
8. Record the date of the member's HCV diagnosis and the likely source of infection.
9. Fill in the member's HCV genotype and subtype, along with HCV-RNA levels and the respective test dates.
10. Document the member's previous HCV treatment, including drug names, dates taken, and treatment results.
11. Answer the questions related to the member’s liver status, including any biopsies or imaging tests performed.
12. Complete the specialized Section III A if the member has cirrhosis, providing detailed information about their current status.
13. Sign and date the form in Section IV, ensuring the prescriber’s details are accurately recorded.
14. Use Section V to include any additional relevant information to support the prior authorization request.
15. After completing all sections, you can save changes, download, print, or share the form.

Complete your WI DHS F-01247 form online today for efficient processing of your prior authorization request.