Get Wi F-11078 2015-2025

Filling out the WI F-11078 form online is a crucial step for pharmacy providers seeking prior authorization for proton pump inhibitor capsules and tablets. This guide will provide clear, step-by-step instructions to ensure users accurately complete the form.

Follow the steps to successfully fill out the WI F-11078 form online.

1. Click the ‘Get Form’ button to access the form electronically and open it in the online document editor.
2. Fill in Section I with the member information, including the member's name, identification number, and date of birth. Ensure all information is accurate and clear.
3. In Section II, provide the prescription information, such as the drug name, strength, date the prescription was written, refills, directions for use, prescriber's name, NPI, address, and telephone number.
4. Complete Section III, which includes clinical information. Enter the diagnosis code and description, and indicate whether the member has had unsatisfactory responses or significant adverse reactions to preferred PPI capsules or tablets.
5. If applicable, provide details for at least two preferred PPI capsules or tablets the member has taken, including the drug name, dosage form, and dates taken. Explain any adverse reactions in the space provided.
6. In Section IV, the prescriber must sign and date the form to authorize the request.
7. For Section V, fill in the details required for pharmacy providers using the STAT-PA system, such as the national drug code, days’ supply requested, NPI, date of service, place of service, assigned PA number, grant date, expiration date, and number of days approved.
8. Finally, Section VI allows you to include any additional information relevant to the request, which may assist in the approval process.
9. Once all sections are completed, users can save changes, download, print, or share the form as necessary.

Complete your documents online with ease by following these steps for the WI F-11078 form.