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Office of Medical Assistance Programs Bureau of FeeforService Programs, Pharmacy Division Phone 18005378862 Fax 18663270191RADICAVA (edaravone) PRIOR AUTHORIZATION FORM (form effective 1/6/2025) Prior
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Gather necessary documents, such as identification and proof of income.
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Visit the official website of the bureau to find the fee-for-service application form.
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Complete the application form by providing accurate personal information and financial details.
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Individuals seeking assistance with healthcare costs.
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The Bureau of Fee-for-Service Programs is a government agency that administers services and programs where providers are reimbursed on a fee-for-service basis for the delivery of specified healthcare services.
Healthcare providers who participate in fee-for-service programs and receive reimbursement for services rendered are required to file with the Bureau of Fee-for-Service Programs.
To fill out the bureau of fee-for-service programs, providers should complete the required forms with accurate information regarding services provided, patient details, and billing data, then submit this form as per the specific filing instructions provided by the bureau.
The purpose of the Bureau of Fee-for-Service Programs is to ensure the proper administration of healthcare services, maintain accountability, prevent fraud, and reimburse healthcare providers fairly for the services delivered.
Providers must report information such as patient identifiers, service codes, dates of service, billing amounts, and any relevant clinical data related to the services provided.
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