Gateway prior auth form 2025

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  1. Click ‘Get Form’ to open the gateway prior auth form in the editor.
  2. Begin with SECTION A - MEMBER INFORMATION. Fill in the last name, first name, date of birth, member ID, and any known allergies along with the type of reaction(s).
  3. Proceed to SECTION B - PHARMACY INFORMATION. Enter the pharmacy name and phone number where the prescription will be filled.
  4. 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.
  5. 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.
  6. Add any additional clinical or supporting information in the designated area.
  7. Complete SECTION D - PRESCRIBER INFORMATION by entering prescriber name (printed), specialty, NPI number, office phone, office fax, and obtaining a signature along with the date.

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