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1. Click ‘Get Form’ to open the Prior Authorization Request Form in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's name, address, city, state, zip code, date of birth, and gender. Include an alternate contact's home phone and relationship to the patient.
3. Next, complete the Insurance Information section. Provide details for both primary and secondary insurance, including subscriber names and identification numbers.
4. In the Prescriber Information section, input the prescriber's name, phone number, office contact name, mailing address, fax number, DEA number, and license number.
5. Fill out the Diagnosis and Clinical Information area with primary and secondary ICD-9 codes along with medical justification for therapy initiation or continuation.
6. Complete the Prescription Information section by selecting prescription type (New Start or Continued Tx), entering medication requested, dosage details, quantity, and expected duration of therapy.
7. Finally, ensure that the prescriber signs and dates the form at the bottom before submitting it via fax to Pharmacy Customer Service.

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