PDF Pharmacy Prior Authorization Request Form - Mercy Care 2025

1. Click ‘Get Form’ to open the PDF Pharmacy Prior Authorization Request Form in the editor.
2. Begin by filling out the 'Member Information' section. Enter the member's name, ID, date of birth, gender, height, and weight accurately.
3. Next, complete the 'Prescribing Provider Information' section. Include the provider's name, specialty, NPI number, DEA number, office address, and contact details.
4. In the 'Dispensing Pharmacy Information' section, provide the pharmacy name and relevant contact information.
5. Fill out the 'Requested Medication Information' section carefully. Indicate if the medication request is for an FDA-approved diagnosis and specify any contraindications.
6. Complete the clinical information questions regarding opioid use disorder and treatment history as required.
7. Finally, ensure all signatures are provided where necessary and review for completeness before submitting.

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