Fillable Prior Authorization Request Form: Medications (Absolute Total Care)

Fill Online, Printable, Fillable, Blank Prior Authorization Request Form: Medications (Absolute Total Care) Form

Use Fill to complete blank online ABSOLUTE TOTAL CARE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Prior Authorization Request Form: Medications (Absolute Total Care)

On average this form takes 14 minutes to complete

The Prior Authorization Request Form: Medications (Absolute Total Care) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 54 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Absolute Total Care forms online.

BROWSE ABSOLUTE TOTAL CARE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Member name
Today’s date
Member plan ID # Date of birth
Drug allergies
Plan name and fax for form submission
I.
Provider
Inf
orma
tion
Prior Authorization Request Form: Medications
Please type or print neatly. Incomplete and illegible forms will delay processing.
II. Member
Inf
orma
tion
Prescriber name NPI #
Prescriber specialty
Phone
Prescriber address
Office contact name
Fax
Pharmacy name Pharmacy phone
III.
Drug Information
(one
drug
per request
f
orm)
Drug name Drug strength Dosage form Dosage interval Quantity per day
Diagnosis relevant to this request
ICD-9 code
Expected length of therapy Number of refills
IV.
Drug History for
this
Dia
gno
sis
A. Is the prescription for a drug to be administered in the office or for the member to take at home? office home
B. Is the member currently treated on this drug? Yes: how long? [go to item C] No [skip items C and D; go to item E]
C. Is this request for continuation of a previous approval? Yes [go to item D] No [skip item D; go to item E]
D. Has strength, dosage or quantity required per day increased or decreased?
Yes [go to item E] No [skip item E; indicate rationale in Section V and submit form]
E. Please indicate previous treatments and outcomes with other medications below.
Drug
name S
trength
Dire
c
tions
Dates of
the
r
apy
Reason
for failure
or
dis
c
ontinu
a
tion
V.
Rationale for
Request and
Pertinent Clinical Information (attach additional
sheets if more space is needed)
Appropriate clinical information to support the request on the basis of medical necessity must be submitted.
Prescriber/Authorized Representative signature Date
Plan F
ax
Number
s
Rev. 08082018
Absolute Total Care . . ..... .... ... 1.866.399.0929
Healthy Blue by BlueChoice of SC . . .... 1.866.807.6241
FFS Medicaid... .... ..... ..... ... 1.888.603.7696
First Choice by Select Health.
..
.
.
1.866.610.2775
Molina Healthcare of SC
. .
. .. .. .... 1.855.571.3011
Wellness of SC. ... . .. .. . .. . .... . 1.866.354.8709
Absolute Total Care 1.866.399.0929
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Prior Authorization Request Form: Medications (Absolute Total Care)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document