Medical Prior Authorization Form



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Medical Prior Authorization Form

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HFS 3082 Drug Prior Authorization Request Form – Illinois.gov

www.illinois.gov

Drug Prior Authorization Request Form. HFS 3082 (R-12-11). DOB: Nine-Digit
HFS Recipient #:. Name: Patient information (required): Name: Fax: NPI #:.
Phone: Prescriber information (required): Phone: Fax: NPI #:. Pharmacy Name:
Pharmacy information (required only when pharmacy is the requesting provider):
Phone:.

PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM

www20.insurance.ca.gov

Instructions: Please fill out all applicable sections on both pages completely and
legibly. Attach any additional documentation that is important for the review, e.g.
chart notes or lab data, to support the prior authorization request. Patient
Information: This must be filled out completely to ensure HIPAA compliance. First
Name:.

prior authorization form – Colorado.gov

www.colorado.gov

Feb 22, 2017 Client's Home. Long-Term Care Facility. Dr.'s Office. Dialysis Unit or Hospital.
Requests that do not include the required information will experience a delay in
the approval process. To expedite this process, please review the prior
authorization criteria in Appendix P at …

Submitting Prior Authorization for Medical and Dental Services

www.hca.wa.gov

Learning Objectives. • As a result of this webinar, you will be able to: ✓ Locate the
prior authorization request form and instructions. ✓ Submit your authorization
request successfully using the authorization intake process. ✓ Package your
request using a document submission cover sheet when additional information is
 …

Brand Name Multi-Source – Mississippi Division of Medicaid – MS.GOV

medicaid.ms.gov

May 5, 2017 SUBMISSION AND/OR APPROVAL OF A DRUG PRIOR AUTHORIZATION
REQUEST DOES NOT GUARANTEE MEDICAID PAYMENT FOR PHARMACY
PRODUCTS OR THE … PLEASE COMPLETE AND FAX DRUG SPECIFIC
CRITERIA/ADDITIONAL DOCUMENTATION FORM FOUND BELOW.

Universal Prior Authorization Medication Form – South Carolina …

msp.scdhhs.gov

Drug allergies. Plan name and fax for form submission. I. Provider Information.
Prior Authorization Request Form: Medications. Please type or print neatly.
Incomplete and illegible forms will delay processing. II. Member Information.
Prescriber name. NPI #. Prescriber specialty. Phone. Prescriber address. Office
contact name.

Medicare Part Prior Authorization for Hospice Form – CMS.gov

www.cms.gov

elements that would be expected to be used in a Part D hospice PA form or
documented by the sponsor when received verbally. Subsequently, the industry
worked through the National Council of Prescription Drug. Plans (NCPDP) Work
Group 9 Hospice Task Group to develop a draft form to be used for documenting
Part.

Prior Authorization Request – Mass.gov

www.mass.gov

Items 1 – 22 PA-1 (Rev. 06/17). MassHealth reviews requests for prior authorization (PA) on
the basis of medical necessity only. If MassHealth approves the request … I certify
under the pains and penalties of perjury that the information on this form and any
attached statement that I have provided has been reviewed and …

Request for Rx Prior Authorization – Maryland Medicaid – Maryland.gov

mmcp.health.maryland.gov

Please check the appropriate box for the Prior Authorization request. □ Quantity
Limit Override □ Age Override … approval, see the Department's Preferred. Drug
list at: https://mmcp.dhmh.maryland.gov/pap/SitePages/Preferred%20Drug%
20List.aspx … Use a separate form for EACH medication request ○. •. Medication
: …

Medication Prior Authorization Form

dhss.alaska.gov

Medication Prior Authorization Form. Not for Botulinum Toxin, Suboxone®/
Subutex® or Synagis® requests. This form may also be used for requesting to
exceed the maximum allowed units. Confidentiality Notice: The documents
accompanying this transmission contain confidential health information that is
legally privileged …

MEDCO-31 – Request for Prior Authorization of Medication Form

www.bwc.ohio.gov

Injured worker information. Request for Prior Authorization of Medication.
Instructions. • The prescriber should only complete this form. • Please fax
completed form to 866-213-6066. • To speak with a customer service
representative, call 877-543-6446. BWC-3931 (Rev. Sept. 8, 2016). MEDCO-31.
Request date. BWC claim …

Prior Authorization Form – eohhs

www.eohhs.ri.gov

RHODE ISLAND MEDICAID PRIOR AUTHORIZATION FORM. Recip MID. Name.
Name. Middle ____ Birth Date. Ordering, Prescribing, Referring Medicaid
Provider Name. ______. Performing/Billing Provider
Name__________________________________________ Return Mailing
Address. City. ST _____ ZIP. Phone …

Prior Authorization (PA) – ahcccs

www.azahcccs.gov

Prior Authorization (PA). How to submit and obtain Prior. Authorizations. March 9,
2017. Gold Room- 701 (3rd floor). 3:00 p.m. – 4:00 p.m. ….. requested to
substantiate medical necessity. • Prior Authorization Correction Form – used to
request changes to an existing. Prior Authorization. Any additional medical
documentation …

C-4AUTH – NYS Workers Compensation Board

www.wcb.ny.gov

The undersigned requests written authorization for the following special service(s
) costing over $1,000 or requiring preauthorization pursuant to the Medical
Treatment Guidelines. Do. NOT use this form for injuries/illnesses involving the
Mid and Low Back, Neck, Knee, Shoulder and Non-Acute Pain, except for the …

Healthy Louisiana Pharmacy Prior Authorization Form

new.dhh.louisiana.gov

Healthy Louisiana Pharmacy Prior Authorization Form. Aetna Better Health of
Louisiana. Phone: 1-855-242-0802 Fax: 1-844-699-2889 www.aetnabetterhealth
.com/louisiana/providers/pharmacy. AmeriHealth Caritas Louisiana. Phone: 1-
800-684-5502 Fax: 1-855-452-9131 www.amerihealthcaritasla.com/pharmacy/
index.

State of Vermont Uniform Medical Prior Authorization Form – Cigna

www.dfr.vermont.gov

Mar 1, 2014 Uniform Medical Prior Authorization Form. Non-Urgent Request. Instructions:
Please complete all fields and submit all additional treatment information and/or
medical notes that support your request for benefits. If you need more room, you
may attach additional pages or forms. Send or fax this information to …

New Hampshire Medicaid Fee-for-Service Program Prior

www.dhhs.nh.gov

SECTION III: CLINICAL HISTORY. 1. Is the prescriber a gastroenterologist,
hepatologist, infectious disease or has one of these specialists been consulted in
this case? Yes. No. If not, has the prescriber completed continuing education
related to Hepatitis C? Yes. No. 2. Does the patient have a diagnosis of Hepatitis
C? Yes.

Pharmacy Authorization – Nevada Medicaid

www.medicaid.nv.gov

May 11, 2017 Prior Authorization Request. Nevada Medicaid – OptumRx. Pharmacy
Authorization. Submit fax request to: 855-455-3303. Purpose: For the prescribing
physician to request prior authorization, when required, for a drug on the
Preferred Drug List. (PDL). Do not use this form for non-preferred drugs or drugs
 …