Get New Hampshire Medicaid Fee-for-service Program Prior Authorization

Filling out the New Hampshire Medicaid Fee-for-Service Program Prior Authorization form online is essential for ensuring that patients receive the medications they need in a timely manner. This guide offers clear, step-by-step instructions to help users navigate the process effectively.

Follow the steps to accurately complete the online form.

1. Click ‘Get Form’ button to obtain the form and open it in the designated platform.
2. Complete Section I: Patient information and medication requested. Fill in the patient’s name, Medicaid number, date of birth, gender, drug name, strength, dosing schedule, length of therapy, number of injections needed, and the HCPC code if applicable.
3. Proceed to Section II: Clinical history. Provide the patient’s diagnosis for the requested medication. Detail any previous treatments that failed or caused adverse reactions, particularly for specific conditions mentioned, such as rheumatoid arthritis or Crohn’s disease.
4. Continue in Section III: Non-preferred drug approval criteria. Identify any allergic reactions or drug interactions that the patient may have experienced. Describe any unacceptable side effects or unique clinical situations that necessitate the use of a non-preferred drug.
5. In Section IV: Facility information, provide the name and NPI number of the facility administering the medication.
6. Fill out Section V: Prescriber information. Enter the group Medicaid ID number, Medicaid provider ID number, the prescriber’s name and NPI number, and their contact phone and fax numbers.
7. Once all sections are completed, review the information for accuracy. The prescriber must sign the form and date it to certify that all provided information is complete and truthful.
8. Finally, save the changes made to the form, then proceed to download or print the document as needed for submission.

Complete your documents online to ensure prompt approval and access to necessary medications.