Superior Prior Authorization Form PDF Details

If you are a healthcare provider, then you know that prior authorization is an important part of the process for getting approvals for treatments and procedures. In order to make the process as smooth as possible, it is important to have a quality prior authorization form. The Superior Prior Authorization Form is designed specifically for this purpose, and it can help you get approvals quickly and easily. This form is available free of charge on our website, and we encourage you to download it today.

We've collected some statistical information regarding the superior prior authorization form. You'll have the assumed time it might require you to fill in the form as well as additional details.

QuestionAnswer
Form NameSuperior Prior Authorization Form
Form Length1 pages
Fillable?Yes
Fillable fields36
Avg. time to fill out7 min 31 sec
Other namessuperior prior authorization form for medication, superior prior auth form pdn ccp, superior health prior authorization form, superior medicaid pa forms

Form Preview Example

MEDICATION PRIOR AUTHORIZATION REQUEST FORM SUPERIOR HEALTH PLAN, TEXAS

(*Do Not Use This Form for Biopharmaceutical Products*)

FAX this completed form to 866-399-0929

OR Mail requests to: US Script PA Dept., 2425 West Shaw Avenue, Fresno, CA 93711

Call 800-460-8988 to request a 72-hour supply of medication.

I. Provider Information

 

II. Member Information

 

 

 

Prescriber name (print):

 

Member name:

 

 

 

Prescriber Specialty:

 

Identification number:

 

 

 

Fax:

Phone:

Date of Birth:

 

 

 

Office Contact Name:

 

Medication allergies:

 

 

 

III.Drug Information (One drug request per form)

Drug name and strength:

Dosage form:

Dosage interval (sig):

Qty per Day:

Diagnosis relevant to THIS request:

Expected length of therapy:

Medication History for this Diagnosis

A.Is member currently treated on this medication?

yes; How Long?_______________ [go to item B]

no [skip items B & C; go to item D]

B.Is this request for continuation of a previous approval?

yes [go to item C]

no [skip item C; go to item D]

C.Has strength, dosage, or quantity required per day increased or decreased?

yes [go to item D]

 

no [skip item D; indicate rationale for continuation in Section IV and submit form]

D.Please indicate previous treatment and outcomes below.

Drug Name (include strength and dosage)

Dates of Therapy

Reason for Discontinuation

1

2

3

4

NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria.

IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)

Appropriate clinical information to support the request on the basis of medical necessity must be submitted.

Provider Signature:

Date:

US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.).

MHP Revised 01-2011

How to Edit Superior Prior Authorization Form Online for Free

Submitting documents together with our PDF editor is easier than nearly anything. To change superior medication prior authorization form the form, there is nothing you will do - just follow the actions down below:

Step 1: The initial step should be to select the orange "Get Form Now" button.

Step 2: You're now allowed to modify superior medication prior authorization form. You have a variety of options thanks to our multifunctional toolbar - you can add, erase, or modify the content, highlight its selected areas, as well as carry out many other commands.

For you to obtain the document, type in the information the software will ask you to for each of the following sections:

superior prior auth form pdn ccp empty spaces to consider

The program will require you to complete the Diagnosis, relevant, to, this, request Expected, length, of, therapy yes, How, Long goto, item, B no, skip, items, BC, goto, item, D yes, goto, it, emC no, skip, it, emC, goto, item, D yes, goto, item, D Drug, Name, include, strength, and, dosage Dates, of, Therapy and Reason, for, Discontinuation segment.

Filling in superior prior auth form pdn ccp part 2

You'll be requested for some important details if you need to fill up the Provider, Signature Date, and M, HP, Revised box.

superior prior auth form pdn ccp ProviderSignature, Date, and MHPRevised blanks to fill out

Step 3: Hit the Done button to save your document. Now it is at your disposal for transfer to your device.

Step 4: Prepare copies of the file. This will protect you from upcoming misunderstandings. We don't look at or disclose your information, therefore feel comfortable knowing it will be protected.

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