Drug Prior Authorization Form PDF Details

In navigating the complexities of healthcare, the Drug Prior Authorization Request Form stands out as an essential tool for ensuring patients receive the necessary medications while adhering to healthcare provider requirements. This form, vital for both patients and practitioners, serves as a gateway to obtaining approval for prescription medications that require prior authorization by insurance companies. It details a comprehensive procedure, starting from submitting patient information in compliance with HIPAA regulations to providing exhaustive details about the prescribed medication, including dosage, frequency, and method of administration. Additionally, the form facilitates the inclusion of critical clinical data, such as previous medications attempted, diagnoses, and required lab results, to support the authorization process. The urgency for accuracy and thoroughness in completing the form cannot be overstated, as it also includes a section for attestation by the prescriber to affirm the authenticity and precision of the submitted information. Moreover, the form is designed to cater to the needs of those requesting authorization for both new therapies and renewals, underlining the importance of detailed record-keeping in patient treatment continuity. Through this form, healthcare providers can articulate the necessity of a particular medication for a patient, backed by clinical evidence and in compliance with insurance policies, thereby paving the way for expedited patient access to critical medication therapies.

QuestionAnswer
Form NameDrug Prior Authorization Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesNPI, PDP, husky d prior authorization forms, CMS

Form Preview Example

Fax this form to: 1-877-269-9916

For specialty drugs fax to: 1-888-267-3277

Aetna Specialty Pharmacy phone: 1-866-503-0857

OR

Submit your request online at:

https://navinet.navimedix.com/Main.asp

PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM

For FASTEST service, call 1-855-240-0535, Monday-Friday, 8 a.m. to 6 p.m. Central Time

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:

Last Name:

MI:

Phone Number:

Address:

City:

State:

Zip Code:

Date of Birth:

Male

Circle unit of measure

 

Allergies:

 

Female

Height (in/cm): ______Weight (lb/kg):______

 

 

 

 

 

 

Patient’s Authorized Representative (if applicable):

Authorized Representative Phone Number:

 

 

 

 

 

Insurance Information

Primary Insurance Name:

Patient ID Number:

Secondary Insurance Name:

Patient ID Number:

First Name:

Prescriber Information

Last Name:

Specialty:

 

 

Address:

City:

State:

Zip Code:

Requestor (if different than prescriber):

Office Contact Person:

NPI Number (individual):

Phone Number:

DEA Number (if required):

Fax Number (in HIPAA compliant area):

Email Address:

 

 

 

 

Medication / Medical and Dispensing Information

 

 

Medication Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Therapy

Renewal

 

 

 

 

 

If Renewal: Date Therapy Initiated:

Duration of Therapy (specific dates):

 

 

 

How did the patient receive the medication?

 

Paid under Insurance Name:

 

Prior Auth Number (if known):

 

Other (explain):

 

 

 

 

 

 

Dose/Strength:

Frequency:

Length of Therapy/#Refills:

Quantity:

Administration:

 

 

 

 

 

 

 

 

Oral/SL

Topical

Injection

IV

Other:

 

 

 

 

 

 

 

 

 

Administration Location:

Patient’s Home

 

 

Long Term Care

 

 

Physician’s Office

 

Home Care Agency

 

Other (explain):

 

 

Ambulatory Infusion Center

Outpatient Hospital Care

 

 

 

 

 

New 08/13

GR-69025-CA (10-14) Page 1 of 2

PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM

Patient Name:

ID#:

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.

1. Has the patient tried any other medications for this condition?

YES (if yes, complete below)

NO

 

 

 

 

 

Medication/Therapy

Duration of Therapy

Response/Reason for Failure/Allergy

(Specify Drug Name and Dosage)

(Specify Dates)

 

 

 

 

 

 

 

 

 

 

 

 

2. List Diagnoses:

ICD-9/ICD-10:

3. Required clinical information - Please provide all relevant clinical information to support a prior authorization review.

Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if patient has any contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed to establish diagnosis, or evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier exceptions) or required under state and federal laws.

Attachments

Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.

Prescriber Signature:

 

Date:

Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for the return or destruction of these documents.

Plan Use Only:

Approved

Date of Decision:

Denied Comments/Information Requested:

 

 

 

 

New 08/13

*5

& $ Page 2 of 2

How to Edit Drug Prior Authorization Form Online for Free

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Step 2: The editor offers you the opportunity to work with almost all PDF files in many different ways. Change it with your own text, correct original content, and put in a signature - all readily available!

It will be simple to complete the pdf using this detailed guide! Here's what you should do:

1. You will want to fill out the authorizations accurately, therefore take care when filling in the parts including these blank fields:

HIPAA completion process described (stage 1)

2. When this array of fields is done, you need to put in the necessary specifics in DEA Number if required, Fax Number in HIPAA compliant area, Email Address, Medication Name, New Therapy, Renewal, Medication Medical and Dispensing, If Renewal Date Therapy Initiated, How did the patient receive the, Paid under Insurance Name, Prior Auth Number if known, Other explain, DoseStrength, Frequency, and Length of TherapyRefills in order to move on further.

Stage # 2 in filling in HIPAA

3. This next part is focused on PRESCRIPTION DRUG PRIOR, Patient Name, Instructions Please fill out all, Has the patient tried any other, YES if yes complete below, MedicationTherapy, Specify Drug Name and Dosage, Duration of Therapy, Specify Dates, ResponseReason for FailureAllergy, List Diagnoses, ICDICD, Required clinical information, Please provide symptoms lab, and Attachments - fill out these blanks.

How one can fill in HIPAA step 3

4. Your next subsection needs your involvement in the following places: Attestation I attest the, Prescriber Signature, Date, Confidentiality Notice The, Plan Use Only, Date of Decision, Approved, Denied CommentsInformation, and New. Be sure that you give all needed information to move forward.

New, Plan Use Only, and Date in HIPAA

Be very careful when filling in New and Plan Use Only, since this is the section where a lot of people make a few mistakes.

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