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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Patient Information' section. Fill in today's date, patient’s first and last name, middle initial, date of birth, address, city, state, zip code, and telephone number.
3. Next, move to the 'Insurance Information' section. Input the BCBS ID number and group number accurately.
4. Proceed to 'Physician/Clinic Information'. Enter the prescriber’s name, NPI number, specialty, clinic name and address details including city, state, zip code, phone number, contact name, and secure fax number.
5. In the additional information section, provide the patient's diagnosis with ICD code and description. Specify the medication requested along with its strength and dosing schedule.
6. Answer whether the patient is currently treated with the requested medication by selecting 'Yes' or 'No', and provide details if applicable.
7. List reasons for selecting this medication over alternatives and any other medications currently being taken for treatment.
8. Finally, attach any additional documentation required for preauthorization consideration before submitting via fax or mail as indicated.

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