Sxc prior authorization form fa 68 2026

1. Click ‘Get Form’ to open the sxc prior authorization form fa 68 in the editor.
2. Begin by entering the DATE OF REQUEST at the top of the form. This is essential for tracking your request.
3. Fill in the RECIPIENT INFORMATION section with the patient's last name, first name, middle initial, recipient ID, date of birth, gender, and phone number.
4. In the PRESCRIBING PROVIDER INFORMATION section, provide your name, NPI number, phone number, fax (required), and a contact person regarding this request.
5. Complete the REQUESTED DRUG section by entering the drug's name, strength, dosage, and duration. Note that generic substitution is not permitted.
6. If applicable, fill out the PREVIOUS THERAPY section with details about any previous medications used including their names, strengths, dosages, and durations.
7. In the CLINICAL INFORMATION section, provide a diagnosis along with ICD-10 codes if available. Include medical justification for product use.
8. Finally, ensure you sign and date in the PROVIDER CERTIFICATION area to confirm that treatment is necessary as per Nevada Medicaid guidelines.

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