Re Professionals OptumRx M/S CA 106-0286 3515 Harbor Blvd. Costa Mesa, CA 92626 Benzodiazepine Prior Authorization Request Form DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Member Information (required) Provider Information (required) Member Name: Provider Name: Insurance ID#: NPI#: Date of Birth: Office Phone: Street Address: Office Fax: City: State: Zip: Phone: Specialty: Office Street Address: City: State: Zip: Medication Informa.
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How to fill out the Buy Benzodiazepines Only online
Filling out the Buy Benzodiazepines Only form is an essential step for obtaining the necessary medications responsibly and efficiently. This guide will provide you with step-by-step instructions on how to complete the form accurately to ensure a smooth submission process.
Follow the steps to effectively fill out the form.
- Press the ‘Get Form’ button to access the form. Once obtained, open it in the appropriate online editor.
- Fill in the required member information, including the member's name, date of birth, and insurance ID number. Ensure accuracy to prevent processing delays.
- Provide your professional details in the provider information section. This includes your name, NPI number, office phone, and address.
- In the medication information section, indicate the medication name and strength. If applicable, check the boxes indicating whether you are requesting a brand or if it is for continuation of therapy.
- Outline the directions for use and select the appropriate dosage form.
- For the clinical information, select the diagnosis that applies from the provided list. If ‘Other diagnosis’ is selected, please specify and provide the corresponding ICD-9/10 code.
- Indicate any medications that the patient has previously failed or had contraindications with. This can support the request for approval.
- Provide the quantity requested per day and the reason for exceeding any plan limitations, selecting from the available options or specifying another reason if needed.
- Add any additional comments, diagnoses, symptoms, medications tried or failed, and any other pertinent information that may aid in the review process.
- Review all the entered information to ensure that it is complete and accurate. Once verified, you can proceed to save changes, download the form, print it, or share it as needed.
Start filling out your form online today to ensure timely access to your medications.
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