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What is Prior Authorization Form
The Physician Certification Prior Authorization Form is a medical document used by physicians to request approval for the dispensing of Increlex®, a treatment for severe IGF-1 deficiency.
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Who needs Prior Authorization Form?
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Prior Authorization Form is needed by:
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Physicians prescribing Increlex®
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Patients with severe IGF-1 deficiency
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Pharmacists dispensing Increlex®
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Healthcare providers managing treatment plans
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Medical consultants reviewing prior authorization requests
How to fill out the Prior Authorization Form
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1.Access pdfFiller and search for the Physician Certification Prior Authorization Form to start.
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2.Open the form by clicking on it in your documents list or using the search function.
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3.Begin by carefully reading any introductory instructions on the form to familiarize yourself with the requirements.
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4.Gather the necessary patient information, physician details, and pharmacy information required for the completion of the form.
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5.Use the toolbar options in pdfFiller to fill out each field as indicated. Click each box or text area to enter your information.
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6.Include all clinical details related to the patient’s condition and treatment plan in the designated sections.
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7.Attach any supporting documentation, such as growth charts and lab work, directly on pdfFiller by uploading files as needed.
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8.Review the completed form thoroughly to ensure all fields are filled correctly and no information is missing.
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9.Sign the form electronically using the signature feature in pdfFiller to validate the submission.
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10.Save your work frequently. Once completed, download the finalized document to your device.
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11.Submit the form according to the instructions provided by ProCare PBM Clinical Division, either electronically or via mail.
Who is eligible to use the Physician Certification Prior Authorization Form?
Eligibility primarily includes licensed physicians who are prescribing Increlex® for patients diagnosed with severe IGF-1 deficiency. Patients receiving the medication may also be required to provide their physician's details.
What supporting documents are required with the form submission?
Along with the completed Physician Certification Prior Authorization Form, supporting documentation such as growth charts and lab results for the patient must be submitted to assist in the authorization process.
How do I submit the completed form?
Once the form is completed and signed, it should be submitted to ProCare PBM Clinical Division either electronically through an approved channel or via traditional mail, depending on the provided submission guidelines.
Are there any common mistakes to avoid when filling out this form?
Common mistakes include providing incomplete patient information, failing to attach required supporting documents, and not signing the form. Ensure all fields are accurately filled before submission.
What is the processing time for the authorization request?
Processing times can vary, but typically it may take several business days for the request to be reviewed and a decision to be communicated. It’s advisable to submit the form as early as possible to avoid delays.
Can this form be notarized before submission?
No, the Physician Certification Prior Authorization Form does not require notarization. However, it must be signed by an authorized medical professional to be valid.
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