Amerigroup Prior Auth Form 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

QuestionAnswer
Form NameAmerigroup Authorization Request
Form Length1 pages
Fillable?Yes
Fillable fields57
Avg. time to fill out11 min 43 sec
Other namesamerigroup authorization form 2020, amerigroup prior auth form, amerigroup online prior authorization, amerigroup prior authorization

Form Preview Example

Ohio Medicaid Managed Care

Pharmacy Prior Authorization Request Form

AMERIGROUP

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

Paramount

Unitedhealthcare Community Plan

Wellcare

 

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

DOB

 

Date

 

 

 

 

Patient ID #

Sex

Medication Allergies

 

 

 

Pharmacy

Pharmacy Phone

 

 

For Injectables Only: Facility Name

For Injectables Only: Facility NPI #

 

 

 

 

Provider Information

Prescriber Name

NPI #

DEA #

 

 

 

Prescriber Specialty

Prescriber Address

 

 

 

 

Office Fax

Phone

Office Contact Name

 

 

 

Medication Requested

 

 

 

 

 

 

 

 

 

Drug Name

 

Strength

 

Dose

Directions (Sig)

 

 

 

 

 

 

 

 

 

 

Duration :

 

Quantity

 

Refills

Diagnosis

Days: ______ Months: ______

 

 

 

 

 

 

 

 

 

Is the Patient currently treated on this medication?

Yes; How Long

 

 

No

 

 

 

 

 

 

 

Patient Previous Medication(s) Relevant to this Request*

 

 

Please indicate previous treatment and outcomes below

 

 

 

 

 

 

Drug Name

Strength

Dose

Directions

 

Duration & Reason for Discontinuation

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

Provider Signature

Date

 

 

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

How to Edit Amerigroup Authorization Request

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