Reasons for Prior Authorization - Print 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION I – MEMBER INFORMATION. Fill in the member's name, ID number, and date of birth clearly.
3. Proceed to SECTION II – PRESCRIPTION INFORMATION. Enter the drug name, strength, date prescription was written, directions for use, prescriber’s name, NPI, address, and phone number.
4. In SECTION III – CLINICAL INFORMATION FOR CROHN’S DISEASE AND ULCERATIVE COLITIS, provide the diagnosis code and description. Answer the questions regarding Crohn’s disease and ulcerative colitis accurately.
5. Detail any previous medications attempted by filling out the relevant fields in SECTION III. Ensure you include specific details about treatment responses.
6. Complete SECTION IV by having the prescriber sign and date the form.
7. If necessary, add any additional information in SECTION V before finalizing your document.

Start using our platform today to streamline your form completion process for free!