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Gateway prior auth form 2026
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- Click ‘Get Form’ to open the gateway prior auth form in the editor.
- Begin with SECTION A - MEMBER INFORMATION. Fill in the member's last name, first name, date of birth, member ID, and any known allergies along with the type of reaction(s) experienced.
- Proceed to SECTION B - PHARMACY INFORMATION. Enter the pharmacy name and phone number where the prescription will be filled.
- In SECTION C - CLINICAL INFORMATION, provide details such as dosage and frequency, quantity, drug name requested, and diagnosis for which the drug is being requested. Document any formulary alternatives that have been used by listing drug names, dates tried, and reasons for therapy failure or discontinuation.
- Indicate if the member is currently or recently hospitalized by checking 'Yes' or 'No', and provide the date of discharge along with the reason for hospitalization if applicable.
- Add any additional clinical or supporting information in the designated area. This may include current office notes or lab data.
- Finally, complete SECTION D - PRESCRIBER INFORMATION by entering the prescriber's name (printed), specialty, NPI number, office phone and fax numbers. Ensure that the prescriber signs and dates the form before submission.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2011 | 4 Satisfied (32 Votes) |
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highmark whole care prior auth form
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