Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Start filling out the member information section. Enter the last name, first name, ID number, date of birth, and gender of the member. Ensure all fields are completed legibly.
3. Next, provide the requesting provider's information. Fill in the provider's name, address, NPI, phone number, and fax number. Make sure these details are accurate to prevent delays.
4. Obtain the provider's signature and date it in the appropriate sections. This confirms that the request is made with consent.
5. Input the product information, including the drug product name, the brand name requested, the start date of treatment (or the date of the next dose), and the date of the last dose if applicable. Don't forget to specify the dosing frequency.
6. In the precertification requirements section, check one of the criteria being met. Fill out each required field related to allergies, color blindness, or epilepsy if applicable.
7. If there is additional information relevant to the request, include it in the designated section. Provide any necessary details to support the authorization request.
8. Before finalizing, review all entries in the form for completeness and clarity. All fields must be completely filled out to ensure a successful review.
9. Once satisfied with the completed form, save the changes, and options for downloading, printing, or sharing it will be available to you.

Ensure timely access to medications by filling out the form online today!