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Get Ucare Injectable Drug Prior Authorization Request Form 2016
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How to fill out the UCare Injectable Drug Prior Authorization Request Form online
Filling out the UCare Injectable Drug Prior Authorization Request Form is a critical step in obtaining the necessary authorization for injectable medications. This guide provides step-by-step instructions to help you seamlessly complete the form online.
Follow the steps to successfully complete the authorization request.
- Press the ‘Get Form’ button to access the request form and open it in your selected editing tool.
- Fill in the request date at the top of the form. Ensure that the date format aligns with the instructions provided.
- In the member information section, complete all required fields, including the member's full name, date of birth, UCare member ID, and address details.
- Next, provide prescriber and clinic information. Include the name of the requesting clinic, a point of contact, their phone number, and fax number. Additionally, enter the ordering prescriber’s name, NPI, specialty, and contact number.
- Indicate the location where the drug will be administered by providing the clinic or facility name, along with the address and contact details.
- In the medication/drug information section, detail the requested drug name, the HCPCS procedure code, and the NDC number. Specify the expected duration of therapy and the authorization start date.
- Respond to the question regarding whether the member is currently being treated with the requested drug. If yes, provide the date treatment started. Also, include the diagnosis related to the drug request along with the relevant ICD-9 or 10 codes.
- Complete the optional sections concerning drug allergies, height, and weight, if applicable. Document any previous drug therapies that were tried and failed, including dates and details regarding adverse reactions or efficacy failures.
- If relevant, describe any conservative treatments attempted without adequate response, including the type of treatment and dates.
- Provide a comprehensive rationale for the request, including the patient’s response to previous treatments if this is a continuation of care. Include any other pertinent clinical information.
- If applicable, list relevant labs or objective information, such as hemoglobin levels and dates drawn for specific drug requests.
- Finally, review all entered information for accuracy. Users can then save changes, download, print, or share the form as needed.
Complete your UCare Injectable Drug Prior Authorization Request Form online today.
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The fax number for Medi-Cal prior authorization requests can vary based on the medication and service type. Generally, you can find the specific fax number on the official Medi-Cal website or in the Medi-Cal provider manual. Make sure to accurately send your completed request form to the correct number to avoid unnecessary delays.
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