Part B Medication Prior Authorization Request Form Form

Part B Medication Prior Approval Request Form This form may ONLY be utilized to submit a request for a service that requires prior approval. PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT REQUEST. Any person who knowingly submits this form containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. PLEASE PRINT OR TYPE THE INFORMATION REQUESTED Forms that are not legible or incomplete will not be processed. Prior authorization priority Standard requests (72 hours) - Fax: 816-313-3015 Expedited requests (24 hours) - Fax: 816-313-3015 Place of service Office Outpatient Home Other
Provider information Name of provider submitting request Individual physician NPI Network status Address City State ZIP Referring provider name Referring provider NPI Name of person completing form (information will be returned to this person) Phone number Fax number Email Scheduled service date Place of service Please note: Request should be submitted 5-7 business days prior to the scheduled date of service in order to allow adequate time for request and receipt of information needed to process the request.

00109.02.02-0323 Patient information First name MI Last name ID number Birth date (mm/dd/yyyy) Gender Address City State ZIP Diagnosis information Diagnosis description J Code NDC number Dosage Units Is the patient currently taking this medication? Yes No If yes, for how long? Previously tried medications Dosage Outcome/Contraindications Additional Information: Please attach and submit any progress notes, lab data, discharge summaries, or other relevant documentation to support discontinuation of previous therapy. DISCLAIMER: Information provided is as of the date of the reply and member information that has been processed. If patient eligibility, benefits, coverage limits, exclusions changes (please check for current patient information on AHIN) or if post claims information does not match this prior approval service request information the approval is not valid. Additional visits or services occurring after the reply date might exceed the limits of the contract or policy and would accordingly not be covered under the contract or policy. Return completed form by fax to: (816) 313-3015