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The document collects subscriber and patient details, prescriber and ordering provider information, and whether the request is initial or continuation/renewal. It captures expedited/urgent review certification, requested drug details including compound ingredients, DME/device information, and patient clinical data such as diagnosis, ICD codes, prior drugs, allergies, relevant labs, and attached justification 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| --- |\n\nSECTION II—REASON FOR REQUEST  \n\n| Check one: |  | □ Initial Request |  | □ Continuation/Renewal Request |\n| --- | --- | --- | --- | --- |\n| Reason for request: (check all that apply) |  |  | □ Prior Authorization\u003Cbr>□ Medical Device\u003Cbr>□ Durable Medical Equipment (DME)\u003Cbr>□ Other (please specify)   |  |\n| □□\u003Cbr>□ | Step Therapy, Formulary Exception\u003Cbr>Quantity Exception\u003Cbr>Specialty Drug |  |  |  |\n\nSECTION III—REVIEW  \n\n| | Expedited/Urgent Review Requested: By checking this box and signing below, I certify that applying the standard review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function. |\n| --- | --- |\n| Signature of Prescriber or Prescriber’s Designee:   |  |\n\nSECTION IV—PATIENT INFORMATION  \n\n| Name: |  | Phone: | DOB: |  |  Male  Female |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Address: |  | City: |  |  |  | State: | ZIP Code: |\n| Subscriber Name (if different from Section I): | Member ID \\#: |  |  | Group Name or Number: |  |  |  |\n| BIN \\# (if available): | PCN (if available): |  |  | Rx ID \\# (if available): |  |  |  |\n\nSECTION V―PRESCRIBER/ORDERING PROVDER INFORMATION  \n\n| Name: |  | NPI \\#: | Specialty: |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Address: |  | City: |  | State: | ZIP Code: |\n| Phone: | Fax: | Office Contact Name: |  | Contact Phone: |  |\n\nSECTION VI―PRESCRIPTION DRUG INFORMATION  \n(If this is a compound drug, identify all ingredients in Section VI, below.)  \n\n| Requested Drug Name: |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Strength: | Route of Administration: | Quantity: | Days’ Supply: | Expected Therapy Duration: |\n| To the best of your knowledge this medication is:\u003Cbr>□ New therapy □ Continuation of therapy (approximate date therapy initiated:  ) |  |  |  |  |\n| For Provider Administered Drugs Only:\u003Cbr>HCPCS Code:   NDC \\#:  Dose Per Administration:   |  |  |  |  |\n\nSECTION VII—PRESCRIPTION COMPOUND DRUG INFORMATION  \n\n| Compound Drug Name: |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Ingredient | NDC \\# | Quantity | Ingredient | NDC \\# | Quantity |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n\nSECTION VIII—PRESCRIPTION DME or MEDICAL DEVICE INFORMATION  \n\n| Requested DME or Medical Device Name: | Expected Duration of Use: | HCPCS Code (If applicable): |\n| --- | --- | --- |\n\nSECTION IX—PATIENT CLINICAL INFORMATION  \n\n| Patient’s diagnosis related to this request: | ICD Version: | ICD Code: |\n| --- | --- | --- |\n| Patient’s diagnosis related to this request: | ICD Version: | ICD Code: |\n\nDrugs patient has taken for this diagnosis: (Provide the following information to the best of your knowledge)  \n\n| Drug Name | Strength | Frequency | Dates Started and Stopped or Approximate Duration |  | Describe Response, Reason for Failure, or Allergy |  |\n| --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| Drug Allergies: |  |  |  | Height (if applicable): |  | Weight (if applicable): |\n\nRelevant laboratory values and dates (attach or list below):  \n\n| Date | Test | Value |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n\nSECTION X―JUSTIFICATION (Provide or attach any additional justification here: Notes, Treatment plans, lab/test results, etc)  \nARIZONA RX/DME PRIOR AUTHORIZATION FORM 12/01/2021 Page 2 of 2","cbCaivFp2d762mfW","https://ap.wps.com/l/cbCaivFp2d762mfW","pdf",262603,"English","# Section I – Submission\n# Section II—Reason for Request\n# Section III—Review\n# Section IV—Patient Information\n# Section V—Prescriber/Ordering Provider Information\n# Section VI—Prescription Drug Information\n# Section VII—Prescription Compound Drug Information\n# Section VIII—Prescription DME or Medical Device Information\n# Section IX—Patient Clinical Information\n# Section X—Justification","[{\"question\":\"What sections are required to submit this prior authorization request?\",\"answer\":\"Submission is organized into Section I through Section X, including subscriber/patient information, reason for request, prescriber details, drug or DME/device details, patient clinical information, and a justification section for supporting notes and attachments.\"},{\"question\":\"How does the form indicate whether the request is initial or a continuation/renewal?\",\"answer\":\"In Section II, it provides checkboxes for “Initial Request” and “Continuation/Renewal Request,” and the applicant selects the applicable option.\"},{\"question\":\"When is expedited/urgent review requested, and what is required?\",\"answer\":\"Section III allows expedited/urgent review by checking the box and providing a signed certification from the prescriber or designee stating that standard review timing may seriously jeopardize the patient’s life or health.\"}]","ARIZONA STANDARDIZED PRIOR AUTHORIZATION REQUEST FOR MEDICATION, DME, AND MEDICAL DEVICE - Submission Form | PDF",1789632143]