Get Narcotic/muscle Relaxant Prior Authorization Request Form - Kdheks

Completing the Narcotic/Muscle Relaxant Prior Authorization Request Form - Kdheks is essential for obtaining necessary approvals for medication. This guide will provide you with clear and user-friendly instructions to help you fill out the form efficiently online.

Follow the steps to successfully complete your prior authorization request.

1. Click ‘Get Form’ button to download the Narcotic/Muscle Relaxant Prior Authorization Request Form and open it for editing.
2. Begin by entering the beneficiary's name in the designated field, followed by their Medicaid ID number and date of birth.
3. Fill out the pharmacy name, Medicaid ID number, and NPI number, alongside the phone and fax numbers of the pharmacy.
4. In the next section, indicate the drug name and the National Drug Code (NDC) requested.
5. Provide the prescribing physician's name, Medicaid ID, NPI number, and contact information, including phone and fax details.
6. Document the prescription instructions (sig), the current dispense date, the number of tablets or capsules being dispensed, and the date of the last dispense along with the number of tablets dispensed.
7. Indicate whether the consumer is in a nursing facility and the length of time they have been on this medication.
8. Describe the diagnosis necessitating this medication. Avoid using codes; clearly state the condition.
9. If the prescribed amount exceeds the recommended maximum dose, explain the medical necessity for the excess dosage.
10. List any other treatments or medications that have been tried, along with the patient’s therapeutic response.
11. Document all other medications the patient is currently using in the provided section.
12. Have the prescribing physician sign and date the form to validate the request.
13. After completing all sections, save your changes. You may also choose to download, print, or share the form as needed.

Complete your prior authorization requests online quickly and efficiently.