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Click ‘Get Form’ to open the Presbyterian Specialty Drug Prior Authorization Request Form in the editor.
Begin by filling out the Patient Information section. Enter the patient's name, date of birth, address, and contact details. Ensure accuracy as this information is crucial for processing.
In the Prescription Information section, provide details about the prescribed drug, including quantity, J-CODE, NDC#, and any refills needed. Include the ICD-9 code and diagnosis to support the request.
Complete the Prescriber Information section by entering the physician's name, signature, specialty, and NPI#. Also include facility address and office staff contact details for follow-up.
Specify Shipping Information by indicating whether to ship to the physician's office or member's home address. Include a date needed for shipping.
Review Internal Information fields for approval status and necessary billing details. Ensure all required checkboxes are marked appropriately.

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