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OPTIMA HEALTH COMMUNITY CARE AND OPTIMA FAMILY CARE (MEDICAID) MEDICAL PRIOR AUTHORIZATION/STEPPED REQUEST* Directions: The prescribing physician must sign and clearly print name (preprinted stamps

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1. To fill out the form, follow these steps:
2. Read through the form carefully to understand the information you need to provide.
3. Gather all the necessary documents and information. This may include personal identification, financial records, or other relevant paperwork.
4. Start filling out the form section by section, following the instructions provided.
5. Provide accurate and complete information in each field or section.
6. Double-check all the information entered to ensure its accuracy.
7. If required, attach any supporting documents or evidence as instructed.
8. Review the completed form to make sure everything is filled out correctly.
9. Sign and date the form if necessary.
10. Submit the form as per the provided instructions.
11. Keep a copy of the filled-out form for your records.

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