Get Wi Dhs F-01247 2017

Completing the WI DHS F-01247 form correctly is essential for submitting a prior authorization request for hepatitis C treatment. This guide provides clear, step-by-step instructions to help users fill out the form easily and efficiently.

Follow the steps to complete the WI DHS F-01247 form online

1. Press the ‘Get Form’ button to obtain the digital version of the form and open it in your editor.
2. Fill out Section I – Member Information. Enter the member's name (last, first, middle initial), member ID number, and date of birth accurately.
3. In Section II – Prescription Information, provide the date the prescription was written, the name of the prescriber, and their National Provider Identifier (NPI). Include the prescriber’s address and telephone number as required.
4. Indicate the proposed hepatitis C drug treatment regimen in Section II by entering the drug names, indicating whether the member is currently taking them, and noting the daily doses.
5. Move to Section III – Clinical Information. Provide the diagnosis code, date of hepatitis C diagnosis, and the likely source of infection.
6. Document the member's HCV genotype and subtype while indicating if a preferred drug is being prescribed. Provide explanations if not.
7. Complete the remaining questions in Section III regarding the member's medical history, including any prior therapies and whether they have liver complications.
8. If applicable, complete Section III A for members with cirrhosis, providing the Child-Turcotte-Pugh score and any additional medical details.
9. Ensure that the prescriber signs and dates the form in Section IV – Authorized Signature.
10. In Section V – Additional Information, include any further diagnostic or clinical details that justify the requested treatment.
11. After carefully reviewing all entries for accuracy, save changes, download, print, or share the form as needed.

Complete your documents online to ensure timely processing of your requests.