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Click ‘Get Form’ to open the amerigroup authorization form in the editor.
Begin by filling out the member information section. Enter the last name, first name, and middle initial of the member, along with their place of residence (Home, Nursing facility).
In the medication information section, provide details such as drug name and strength requested, Amerigroup ID number, date of birth, height, weight, and SIG (dose, frequency, and duration).
Complete the diagnosis and/or indication field. If applicable, indicate whether the member has tried other medications for this condition and provide supporting documentation if necessary.
Fill in prescriber information including last name, NPI number (required), DEA/license number, and contact details.
Finally, review all sections for completeness before signing. Ensure that all required fields are filled out accurately to avoid delays in processing.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (42 Votes)
2017	4.3 Satisfied (24 Votes)
2012	4.3 Satisfied (55 Votes)

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What is the purpose of an authorization form?

By signing the authorization, an individual is giving consent to have their health information used or disclosed for the reasons stated on the authorization. Any use or disclosure by the covered entity or business associate must be consistent with what is stated on the form.

How do I get insurance authorization?

The patient or their representative can contact their insurance company and provide the relevant information to start the Prior Authorization process. Its best to confirm with the healthcare provider if they have the information and are willing to submit the request.

What is a medical authorization form?

Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals and durable medical equipment requests.

What is the fax number for Amerigroup authorization?

3. To help us expedite your Medicaid authorization requests, please fax all the information required on this form to 844-487-9292.

What is a medical authorization?

A typical medical authorization form grants authorization from you, the patient, to a third party, like your insurance company, for access to your medical records. Depending on the agreement, the scope may be limited or broad.

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