Are you looking for a way to easily and quickly fill out important health forms? The Medco 31 form is an invaluable tool that helps make streamline the administrative process of taking care of your healthcare needs. This paperless solution helps medical practices save both time and money by allowing them to securely store, manage, and submit the necessary documents. While there are many different forms used in healthcare today, the Medco 31 form stands out due to its efficiency and user-friendly design. Read on to learn more about this powerful web-based application and how it can help enhance your experience with medical paperwork!
| Question | Answer |
|---|---|
| Form Name | Medco 31 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ICD-9, amerigroup authorization form, amerigroup prior authorization, Justification |
Request for Prior Authorization of Medication
Instructions
•The prescriber should only complete this form.
•Please fax completed form to
•To speak with an SXC customer service representative, please call
Injured worker information
Request date
BWC claim number
Injured worker name
Injured worker date of injury
Prescriber information
Prescriber
Prescriber NPI
Prescriber phone
Prescriber fax number
Medication requested and conditions being treated (Required)
Medication name |
1.
2.
3.
4.
Brand name drug: The injured worker has a documented, systemic allergic reaction, which is consistent with known symptoms or clinical indings of a medication allergy and has tried other generic drug(s).
Post surgical medication request
Date of scheduled surgery
Justification for request (Required - attach separate sheet if needed.)
Please document how the medication(s) requested is/are related to the treatment of or the control of symptoms associated with the allowed conditions in the claim.
Prescriber signature (required)
Signature date