Amerigroup Authorization Request PDF Details

Amerigroup Authorization Request is a document that can be used to request authorization for Amerigroup services. This document specifies the individual's diagnosis, medications, and any other information that may be important in determining eligibility for coverage under the Amerigroup health care plan. The form also requires authorizing signatures of both physician and patient. This is an example of what this type of form would look like: A completed Amerigroup Authorization Request Form must include all relevant medical information about the individual requesting coverage as well as their current prescriptions (including dosage). It should also include statements from both the physician who will oversee treatment with Amerigroup and from the person seeking coverage, outlining why they are requesting authorization for healthcare services through this company.

You could find it beneficial to know the amount of time you will need to prepare this amerigroup authorization re

Form NameAmerigroup Authorization Request
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesamerigroup prior authorization, amerigroup auth req form, amerigroup therapy request form, amerigroup prior auth form

Form Preview Example

Ohio Medicaid Managed Care

Pharmacy Prior Authorization Request Form


Buckeye Community Health Plan

CareSource Ohio

Molina Healthcare of Ohio

FAX: 800-359-5781

FAX: 866-399-0929

FAX: 866-930-0019

FAX: 800-961-5160

Phone: 800-454-3730

Phone: 866-399-0928

Phone: 800-488-0134

Phone: 800-642-4168


Unitedhealthcare Community Plan



FAX: 419-887-2028

FAX: 866-940-7328

FAX: 877-277-6892


Phone: 800-891-2520

Phone: 800-310-6826

Phone: 800-678-3184


Patient Information




Patient Name








Patient ID #


Medication Allergies





Pharmacy Phone



For Injectables Only: Facility Name

For Injectables Only: Facility NPI #





Provider Information

Prescriber Name






Prescriber Specialty

Prescriber Address





Office Fax


Office Contact Name




Medication Requested










Drug Name





Directions (Sig)











Duration :






Days: ______ Months: ______










Is the Patient currently treated on this medication?

Yes; How Long











Patient Previous Medication(s) Relevant to this Request*



Please indicate previous treatment and outcomes below







Drug Name





Duration & Reason for Discontinuation





































































































Relevant Medical Rationale for Request/Additional Clinical Information (Including diagnostic studies and lab results)*



Provider Signature




*In order to process this request, please complete all boxes completely and attached relevant notes when appropriate.

How to Edit Amerigroup Authorization Request Online for Free

It is simple to fill in forms taking advantage of our PDF editor. Modifying the amerigroup prior authorization form texas document is effortless in case you consider the following steps:

Step 1: To get going, choose the orange button "Get Form Now".

Step 2: At the moment you're on the form editing page. You can modify and add text to the document, highlight words and phrases, cross or check specific words, add images, put a signature on it, delete unneeded areas, or take them out completely.

The next sections are contained in the PDF form you will be completing.

entering details in amerigroup online prior authorization part 1

Fill out the Office Fax, Phone, Office Contact Name, Medication Requested, Drug Name, Strength, Dose, Directions Sig, Duration Days Months Is the, Quantity, Refills, Diagnosis, Yes How Long, Patient Previous Medications, and Please indicate previous treatment field using the information asked by the software.

Completing amerigroup online prior authorization step 2

Step 3: When you click the Done button, your prepared form can be easily transferred to any kind of your gadgets or to email specified by you.

Step 4: Try to get as many copies of the form as you can to avoid possible complications.

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