66-399-0928 Phone: 800-488-0134 Paramount FAX: 419-887-2028 Phone: 800-891-2520 Unitedhealthcare Community Plan Wellcare FAX: 866-940-7328 FAX: 877-277-6892 Phone: 800-310-6826 Phone: 800-678-3184 Patient Information Patient Name DOB Molina Healthcare of Ohio FAX: 800-961-5160 Phone: 800-642-4168 Date Patient ID # Sex Pharmacy Pharmacy Phone For Injectables Only: Facility Name For Injectables Only: Facility NPI # Provider Information Prescriber Name NPI # DEA # Prescriber Special.
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How to fill out the OH OH-P-1175 online
The OH OH-P-1175 form, used for Ohio Medicaid Managed Care prior authorization requests, is an essential document for healthcare providers seeking approval for patient treatments. In this guide, we will provide you with clear, step-by-step instructions on how to effectively complete this form online, ensuring that you include all necessary information.
Follow the steps to successfully complete the OH OH-P-1175 form online.
- Press the ‘Get Form’ button to retrieve the OH OH-P-1175 document and open it in your preferred editor.
- Begin by filling out the 'Patient Information' section. Provide the patient’s name, date of birth (DOB), patient ID number, sex, pharmacy name, and pharmacy phone number. If the request is for injectables, also include the facility name and NPI number.
- Move to the 'Provider Information' section. Enter the prescriber’s name, NPI number, DEA number, prescriber specialty, address, as well as office fax and phone number.
- In the 'Medication Requested' section, list the drug name, strength, dose, duration, quantity, and the number of refills. Specify if the patient is already being treated with this medication and include how long they have been using it.
- Complete the 'Patient Previous Medication(s) Relevant to this Request' section by providing information on previous treatments, including the drug name, strength, dose, directions, and any relevant diagnosis or reasons for discontinuation.
- Provide a detailed explanation in the 'Relevant Medical Rationale for Request/Additional Clinical Information' section. This should include any necessary diagnostic studies, lab results, and other pertinent clinical information to support the request.
- Lastly, sign and date the form at the 'Provider Signature' section to authenticate the submission.
- After completing the form, ensure all fields are accurately filled. You can then save the changes, download the completed form, print it, or share it as required.
Complete your Ohio Medicaid Managed Care prior authorization requests online today!
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