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Requires ICD-10 diagnosis codes and prior precertification documentation: medical condition, medical rationale, prior therapies, and optional additional considerations, including evidence requirements for non-approved indications, dosing, or routes.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/medical-prior-authorization-form-fax-completed-form/287398/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medical-prior-authorization-form-fax-completed-form/287398.png","ImageObject",442,249,{"name":42,"@type":43},"WPS_1786070896","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",5,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required to submit a medical drug authorization request?","Question",{"text":63,"@type":64},"The form collects member details, requesting/primary care physician information, the requested drug and dosing schedule, administration place, billing method, and ICD-10 diagnosis codes. It also requires prior precertification documentation about the patient’s condition and medical rationale.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does the form define Urgent versus Non-Urgent requests?",{"text":68,"@type":64},"Urgent requests are those where standard review time may seriously jeopardize the patient’s life or health or ability to regain maximum function. Non-Urgent requests use standard review.",{"name":70,"@type":61,"acceptedAnswer":71},"What additional evidence is needed for coverage of non-FDA-approved indications, dosing, or routes?",{"text":72,"@type":64},"Authorization for indications, dosing, or a route not approved by the FDA or not recognized in accepted CMS compendia requires supporting evidence. The form requests two published peer-reviewed literature articles supporting the appropriateness of the drug, dosing, or route for the identified indication.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},287398,1789632289,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},21,"Paper Templates","papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":80,"read_time":22},549768072016,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Medical prior authorization form  \nFax completed form to: 877.974.4411 toll free, or 616.942.8206  \nThis form applies to:  Commercial (Traditional)  Commercial (Individual/Optimized)  \nThis request is:  Urgent (life threatening)  Non-Urgent (standard review)  \nUrgent means the standard review time may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function.  \nMedical Drug authorization request  \n\n| Member\u003Cbr>Last Name:   ID \\#:   Primary Care Physician:  \u003Cbr>Requesting Physician:   Physician Address:\u003Cbr>Physician NPI:  \u003Cbr>Physician Signature:   | First Name:   DOB:   Gender:  \u003Cbr>Prov. Phone:   Prov. Fax:   |\n| --- | --- |\n|  | Contact Name:  \u003Cbr>Date:   |\n\nProduct and Billing Information  \n New Request  Continuation Request  \nDrug requested:   \nStrength:   \nStart date (or date of next dose):   Date of last dose (if applicable):    \nDate of next dose (if applicable):   Dose:  Dose Frequency:  BSA (if applicable):   \nWeight (if applicable):   \nPlace of administration:  Physician’s office  \n Outpatient infusion  \nFacility:   NPI:  Fax:   Home infusion  \nAgency:   NPI:  Fax:   \nBilling:  Physician to buy and bill  \n Facility to buy and bill  \n Specialty Pharmacy  \nPharmacy:  NPI:  Fax:   \nICD-10 Diagnosis code(s):    \nNote: Authorization for indications, dosing, or a route of administration not approved by the Food and Drug Administration (FDA) or recognized in CMSaccepted compendia (e.g. DrugDex, AHFS, U.S. Pharmacopeia, and also Clinical Pharmacology for oncology indications only) require supporting evidence for coverage. Please provide two published peer-reviewed literature articles supporting the appropriateness of the drug, the dosing of the drug, or the route of administration to be used for the identified indication.  \nPriority Health Precertification Documentation  \nA. List the patient’s medical condition the drug is being requested for:    \nB. Explain the medical reason for this request:  \nC. List previous drugs the patient tried. (List the name, date prescribed, and any other important information. ) Drug name Strength Dosing schedule/frequency Date prescribed Date stopped  \nD. Provide any additional information for consideration (optional) :    \n|  |\n| --- |\n|  |\n|  |\n|  |","cbCaiiSCYOn25tYj","https://ap.wps.com/l/cbCaiiSCYOn25tYj","pdf",139736,"English","# Form Overview\n## Request Type and Review Priority\n# Member and Physician Information\n# Product and Billing Information\n## Drug, Dose, Administration Setting\n# Priority Health Precertification Documentation\n## Patient Condition and Medical Reason\n## Prior Drug Therapies\n## Additional Optional Information","[{\"question\":\"What information is required to submit a medical drug authorization request?\",\"answer\":\"The form collects member details, requesting/primary care physician information, the requested drug and dosing schedule, administration place, billing method, and ICD-10 diagnosis codes. It also requires prior precertification documentation about the patient’s condition and medical rationale.\"},{\"question\":\"How does the form define Urgent versus Non-Urgent requests?\",\"answer\":\"Urgent requests are those where standard review time may seriously jeopardize the patient’s life or health or ability to regain maximum function. Non-Urgent requests use standard review.\"},{\"question\":\"What additional evidence is needed for coverage of non-FDA-approved indications, dosing, or routes?\",\"answer\":\"Authorization for indications, dosing, or a route not approved by the FDA or not recognized in accepted CMS compendia requires supporting evidence. The form requests two published peer-reviewed literature articles supporting the appropriateness of the drug, dosing, or route for the identified indication.\"}]","Medical Prior Authorization Form - Fax Completed Form | PDF"]