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Illinois prior authorization form 2026
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- Click ‘Get Form’ to open the Illinois Prior Authorization Request Form in our platform's editor.
- Begin by filling out the 'Patient Information' section. Enter the patient's name, date of birth, and nine-digit HFS Recipient number.
- Next, complete the 'Prescriber Information' section. Input the prescriber's name, phone number, fax number, and NPI number.
- If applicable, provide 'Pharmacy Information' by entering the pharmacy name and contact details.
- In the 'Medication' section, specify the medication name, strength, NDC number (if available), effective begin date, refills needed, and quantity.
- Indicate whether this is a new prescription or a renewal and include directions for use along with diagnosis or ICD code.
- List all medications previously tried for this indication and describe any failures experienced.
- Provide additional information justifying the need for this medication over alternatives that do not require prior authorization.
- If requesting an override of limitations, check the appropriate boxes provided in the form.
- Finally, ensure that the prescriber or designee signs and dates the form before submission.
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il prior authorization form pdf
Patient Information. Name: Last. First. (MI) . Date of Birth: / /. University of Chicago MRN (if applicable):. Gender: Male. Female.
Illinois Medicaid Pharmacy Prior Authorization Request Form. State of Illinois. Department of Healthcare and Family Services. Fax completed form to patients
Prior Authorization Request Form, is available in the Healthcare Services section of this. 13. Page 14. Manual. Physician administered drugs require the