Follow the steps to successfully complete the form

1. Press the ‘Get Form’ button to access the Cigna Uniform Pharmacy Prior Authorization Request Form and open it in your browser.
2. Begin by entering the patient information. Include the patient's name, date of birth, member or subscriber number, policy or group number, and address. This information is essential for identifying the patient and verifying their coverage.
3. Next, fill in the prescribing provider information. Provide the prescriber's name, fax number, phone number, pager number, address, email address, NPI, DEA, and tax ID. This section confirms who is prescribing the medication.
4. Indicate whether the request is urgent or non-urgent, and enter the requested drug name along with any relevant clinical information, such as the patient's diagnosis and ICD codes.
5. Detail the medication specifics, including drug(s) requested, their strength, route of administration, frequency, unit or volume, start date, and length of therapy.
6. Specify the location of treatment, including the healthcare facility or home health type and any pertinent addresses or tax IDs.
7. In the section for clinical criteria, provide necessary details to support the request, including other medications tried, their names, duration, and patient response.
8. If applicable, indicate if the drug is for use in a clinical trial by providing the trial name and registration number.
9. Include any additional prescription information, such as drug name (both brand and scientific), dose, route, quantity, and refills.
10. Choose the delivery option for the product—whether it will be sent to the patient’s home or physician's office.
11. At the bottom of the form, the prescriber must sign and date, confirming the information provided.
12. Finally, review the completed form for accuracy. Save changes, and download, print, or share the form as needed.

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