Get the free Prior Authorization Request Form - MDwise
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Member Name:Prior Authorization Request Form Member ID#: Member DOB:Name of Requesting Provider:Name of Rendering Provider/Name of Service Location:City/State: Requesting Provider NPI#:City/State:
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How to fill out prior authorization request form
How to fill out prior authorization request form
01
Write your name, contact information, and date of birth at the top of the form.
02
Provide your insurance policy number and the name of your insurance provider.
03
Specify the medication or treatment for which you are seeking prior authorization.
04
Include the name, address, and contact information of your healthcare provider who prescribed the medication or treatment.
05
Attach any supporting documentation or medical records that may be necessary to justify the need for prior authorization.
06
Sign and date the form before submitting it to your insurance provider.
07
Keep a copy of the completed form for your records.
Who needs prior authorization request form?
01
Individuals who have health insurance coverage and need to request prior authorization for a specific medication or treatment.
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