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DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F01247 (07/2019)STATE OF WISCONSIN Wis. Admin. Code DHS 107.10(2)FORWARDHEALTHPRIOR AUTHORIZATION DRUG ATTACHMENT FOR HEPATITIS C AGENTS

How to fill out prior authorization request form

How to fill out prior authorization request form

1. Step 1: Obtain the prior authorization request form from the relevant insurance company or healthcare provider.
2. Step 2: Fill out the personal and patient information sections accurately, including name, date of birth, address, insurance policy number, and contact information.
3. Step 3: Provide the necessary details about the medical procedure or treatment requiring prior authorization, including the diagnosis, recommended medication or therapy, and the healthcare provider's information.
4. Step 4: Attach any supporting documents, such as medical records, test results, or physician notes that justify the need for the requested procedure or treatment.
5. Step 5: Review the completed form and ensure all information is correct and legible.
6. Step 6: Submit the filled-out prior authorization request form to the designated authority, such as the insurance company or healthcare provider, either by mail, fax, or online submission.
7. Step 7: Keep a copy of the submitted form for your records and follow up with the authority to confirm receipt and obtain any updates regarding the request.

Who needs prior authorization request form?

1. Anyone seeking coverage for a medical procedure, treatment, or medication that requires prior authorization from their insurance company or healthcare provider needs to fill out the prior authorization request form.

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What is prior authorization request form?

Prior authorization request form is a document that must be submitted to an insurance company or healthcare provider before certain medical services or prescriptions are approved for coverage.

Who is required to file prior authorization request form?

Healthcare providers, including physicians, hospitals, and pharmacies, are typically required to file prior authorization request forms.

How to fill out prior authorization request form?

Prior authorization request forms can usually be filled out online or on paper, and require information such as patient demographics, medical diagnosis, and treatment plan.

What is the purpose of prior authorization request form?

The purpose of a prior authorization request form is to ensure that medical services or prescriptions meet certain criteria for coverage, such as medical necessity and cost effectiveness.

What information must be reported on prior authorization request form?

Information that must be reported on a prior authorization request form includes patient's name, date of birth, medical diagnosis, treatment plan, and healthcare provider's information.