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Click ‘Get Form’ to open it in the editor.
Begin by identifying who is making the request. Select either 'Provider', 'Member', or 'Appointed Representatives' and ensure you attach any necessary documentation.
Choose between a Standard Review (72 hours) or an Expedited Review (24 hours) by checking the appropriate box. Remember, selecting expedited indicates urgency regarding the member's health.
Fill in the member's details including Name, ID#, Address, Phone, Height/Weight, Allergies, Date of Birth, Diagnosis, ICD9 code, and Dose.
Provide your information as the provider: Name, Address, Phone, Fax, Contact Name, and Provider ID/NPI.
Indicate the Frequency of treatment and Length of Treatment required.
Document clinical rationale for any override requests and list previous medications tried and failed.
Answer all questions regarding the member’s care setting accurately to ensure thorough review.

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Versions	Form popularity	Fillable & printable
2010	4.9 Satisfied (62 Votes)

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