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Coventry chch prior form get 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'Requesting Physician' section, including your Call Center ID, Office Contact, Tax ID Number, Plan ID, Office Fax Number, Benefit, Phone Number, and Office Address.
- In the 'MEMBER INFORMATION' section, enter the Patient Name, DOB, Member ID#, and Date of Request.
- Proceed to the 'MEDICATION INFORMATION' section. Select the drug requested (Lyrica, Cymbalta, or Savella) and provide details of past treatment trials including specific drugs used and their therapeutic outcomes.
- Indicate whether the member failed non-pharmacologic therapy by selecting YES or NO. If applicable, list therapies tried in the provided space.
- Finally, ensure you sign in the designated area for the Physician’s Signature before submitting your completed form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2009 | 4.8 Satisfied (178 Votes) |
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