Cigna Uniform Pharmacy Prior Authorization Request Form 2014 free printable template

UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete this form in its entirety and send to: Phone: (800) 2446224 Urgent Requested Drug Name: Patient

How to fill out Cigna Uniform Pharmacy Prior Authorization Request

How to fill out Cigna Uniform Pharmacy Prior Authorization Request Form

1. Obtain the Cigna Uniform Pharmacy Prior Authorization Request Form from the Cigna website or your healthcare provider.
2. Fill out the patient's information including name, date of birth, and insurance details.
3. Specify the medication name, dosage, and frequency prescribed by the healthcare provider.
4. Complete the clinical information section with relevant medical history and diagnosis.
5. Include any previous medications tried and their outcomes.
6. Attach any supporting documentation such as lab results or previous treatment records.
7. Review the form for accuracy and completeness.
8. Sign and date the form, affirming that the information is correct.
9. Submit the form via fax or online as instructed by Cigna.

Who needs Cigna Uniform Pharmacy Prior Authorization Request Form?

1. Patients who require prior authorization for specific medications covered by Cigna insurance.
2. Healthcare providers submitting requests on behalf of their patients.
3. Pharmacists needing to verify the authorization for medication dispensing.

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What is Cigna Uniform Pharmacy Prior Authorization Request Form?

The Cigna Uniform Pharmacy Prior Authorization Request Form is a document used by healthcare providers to request pre-approval for certain medications from Cigna, ensuring that the prescribed drugs are covered under a patient's insurance plan.

Who is required to file Cigna Uniform Pharmacy Prior Authorization Request Form?

Healthcare providers, including physicians and pharmacists, are required to file the Cigna Uniform Pharmacy Prior Authorization Request Form when prescribing medications that require prior authorization from Cigna.

How to fill out Cigna Uniform Pharmacy Prior Authorization Request Form?

To fill out the Cigna Uniform Pharmacy Prior Authorization Request Form, complete all required fields including patient information, prescriber details, medication details, and clinical information supporting the need for the prescribed medication.

What is the purpose of Cigna Uniform Pharmacy Prior Authorization Request Form?

The purpose of the Cigna Uniform Pharmacy Prior Authorization Request Form is to determine the medical necessity of certain medications before they are dispensed, ensuring appropriate use of healthcare resources and adherence to insurance plan guidelines.

What information must be reported on Cigna Uniform Pharmacy Prior Authorization Request Form?

Information that must be reported on the Cigna Uniform Pharmacy Prior Authorization Request Form includes patient identification, prescribing provider information, medication name, dosage, quantity, diagnosis or condition being treated, and justification for the medication use.