Bcbs prior authorization form pdf 2026

1. Click ‘Get Form’ to open the BCBS Prior Authorization Form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter today's date, patient’s first and last name, gender, date of birth, address, city, state, zip code, and telephone number.
3. Next, complete the 'Insurance Information' section by providing the BCBS ID number and group number.
4. In the 'Physician/Clinic Information' section, input the prescriber’s name, NPI number, specialty, clinic name and address, phone number, contact name, and secure fax number.
5. For the medication requested (AMPYRA 10mg), answer all relevant questions regarding patient diagnosis and therapy history. Ensure to provide details about concurrent therapies if applicable.
6. Finally, review all sections for completeness. Attach any additional documentation required before submitting via fax or mail as indicated at the bottom of the form.

Start using our platform today to fill out your BCBS Prior Authorization Form easily and for free!