FORMULARY EXCEPTION PHYSICIAN FAX FORM ONLY the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews. Incomplete forms will be returned for additional.
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How to fill out the IL 6002 ILFHP FECR 0114 online
Filling out the IL 6002 ILFHP FECR 0114 form online can simplify the process of requesting medication prior authorization. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.
Follow the steps to successfully complete the form online.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the patient information. Provide the date, the patient's first and last name, middle initial, date of birth (mm/dd/yyyy), address, city, state, zip code, and telephone number.
- Input the insurance information, including the BCBS ID number and the group number.
- Fill in the physician or clinic information. Include the prescriber's name, NPI number, specialty, clinic name, clinic address, city, state, zip code, phone number, contact name, and secure fax number.
- Attach any additional documentation necessary for preauthorization consideration. Clearly indicate the patient's diagnosis along with the ICD code and a brief description.
- Specify the medication requested, including its strength, dosing schedule, and the quantity required per month.
- Indicate whether the patient is currently being treated with the requested medication by selecting 'Yes' or 'No'. If 'Yes', provide the date treatment started.
- List all reasons for selecting the requested medication over alternatives, including any contraindications, allergies, or histories of adverse drug reactions.
- Document all medications the patient is currently taking for treatment of the diagnosed condition.
- Detail all medications the patient has previously tried and failed for the same diagnosis, specifying if they were brand-name, generic, or over-the-counter products.
- After all sections are completed, save the changes, download the form, print, or share it as required.
Complete the IL 6002 ILFHP FECR 0114 form online today for a streamlined medication request process.
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