Follow the steps to complete the AZ Mercy Care C14565-A form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editing program.
2. Begin by entering the member information. Provide the member's first and last name, member ID, date of birth, gender, and address details, including state and city.
3. Fill in the prescribing provider's information. Input the provider's full name, specialty, NPI number, DEA number, office address, city, state, zip code, contact information, and both office and pharmacy phone and fax numbers.
4. Provide dispensing pharmacy information by entering the pharmacy's name.
5. Complete the medication requested section. Answer whether the request is for an FDA approved or compendia-supported diagnosis, specify if there are contraindications to formulary medications, and detail the directions for use, diagnosis, ICD-10 code, strength, quantity, dosage form, and days' supply.
6. Indicate if it is a new request or a continuation of therapy. Specify the duration of therapy and any previous medications tried and failed with the member.
7. For clinical information, answer the questions regarding the member's opioid use disorder status, current medication maintenance, and psychosocial interventions related to their treatment.
8. If applicable for renewal requests, answer questions about documentation and adherence to medication policies.
9. Add any additional information that the prescribing provider feels is important for the review process.
10. Ensure completeness of the form. Confirm that all requested documents, like office notes and lab results, are included. Finally, sign and date the form to attest to the accuracy of the information provided.
11. Once completed, save the changes, and you can download, print, or share the form as needed.

Start filling out the AZ Mercy Care C14565-A form online today!