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The document is a Prior Authorization Request Form for biologic therapy treatments for inflammatory arthritis, including medications such as Enbrel, Humira, and Remicade. It outlines the necessary information required from prescribing physicians and patients for both initial and continuation therapy requests, including patient details, drug requested, dosage, diagnosis, and supporting medical documentation. The form emphasizes the need for accurate information and the submission of relevant medical records before review.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your submission.
Fill in the 'Prescribing Physician Information' section, including your name and NPI number, ensuring accuracy for processing.
Complete the 'Member Information' section with details such as ID number, address, birthdate, and contact information.
Select the drug requested from the list provided and specify dosage, frequency, and duration of therapy.
Indicate whether this is an initial or continuation request by checking the appropriate box.
For additional information, fill out any relevant medical history or symptoms in the designated sections.
Finally, ensure you sign and date the form before submitting it through our platform for processing.

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