Edit, Download, and Sign the Keystone First Universal Pharmacy Authorization Form
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How do I fill this out?
To fill out this form, begin by entering the patient's details at the top of the document. Next, provide the physician's information and medication requested. Finally, complete the diagnosis and therapy length to submit the request appropriately.
How to fill out the Keystone First Universal Pharmacy Authorization Form?
1
Fill in the patient’s personal information accurately.
2
Provide the physician’s details including name and contact.
3
Specify the medication name and its strength.
4
Indicate the anticipated length of therapy.
5
Sign and submit the form as instructed.
Who needs the Keystone First Universal Pharmacy Authorization Form?
1
Healthcare providers need this form to request medication approvals for patients.
2
Patients may need it to ensure their prescribed medications are covered.
3
Pharmacies require it to verify prior authorizations before dispensing medications.
4
Insurance companies utilize it to manage medication costs and approvals.
5
Care coordinators may need it to assist patients with medication access.
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What are the instructions for submitting this form?
To submit this form, complete all required fields and ensure accuracy. Send the completed form to PerformRx at 200 Stevens Drive, Philadelphia, PA 19113 or fax it to 1-215-937-5018. For injectable requests, call 1-800-588-6767 for further instructions.
What are the important dates for this form in 2024 and 2025?
Important dates for this form include submission deadlines dictated by Keystone First for medication requests. Keep an eye on updates for 2024 and 2025 to ensure timely submissions. Regularly check for any changes in policy that might affect these timelines.
What is the purpose of this form?
The primary purpose of this form is to facilitate the prior authorization process for medications under Keystone First. It serves to collect necessary information from both the patient and the prescribing physician, ensuring a comprehensive review can be conducted. Ultimately, this form aims to streamline the access to necessary medications while adhering to insurance requirements.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Full name of the patient requesting the medication.
- 2. Patient DOB: Date of birth of the patient.
- 3. Patient ID Number: Unique identifier assigned to the patient by the insurance.
- 4. Physician Name: Name of the physician prescribing the medication.
- 5. Phone: Contact number for the physician.
- 6. Fax: Fax number for submission.
- 7. Medication Name and Strength Requested: Name and strength of the medication requested.
- 8. Anticipated Length of Therapy: Duration for which the medication is being requested.
- 9. Diagnosis: Relevant medical diagnosis pertaining to the request.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in medication approval, potentially impacting patient care. Without proper authorization, the prescribed medication may not be dispensed at the pharmacy. It is crucial to ensure that the form is accurately completed and submitted on time.
- Delayed Treatment: Patients may experience delays in obtaining necessary medications.
- Increased Out-of-Pocket Costs: Without prior authorization, patients may face higher costs for medications.
- Disruption in Care: Failure to obtain prior authorization could disrupt ongoing treatment plans.
How do I know when to use this form?
- 1. Requesting Non-Preferred Medications: For medications that are not on the chosen formulary.
- 2. Extending Treatment Length: When needing to authorize medication beyond typical duration.
- 3. Starting New Therapies: When initiating therapies that require prior approval.
Frequently Asked Questions
What is the purpose of this form?
This form helps in submitting prior authorization requests for medications.
How do I access this form?
You can download the form directly from our website.
Can I edit the PDF after downloading?
Yes, you can edit the PDF using PrintFriendly's editing tools.
Is this form applicable for all medications?
This form is specifically for medications that require prior authorization.
How do I submit the filled form?
You can fax or mail the completed form to the provided contact details.
What should I do if I encounter issues?
Feel free to reach out for assistance via our support channels.
Can I sign this document electronically?
Yes, the PDF editor allows electronic signatures.
What information do I need to fill out?
You will need patient and physician information, medication requested, and length of therapy.
Is this form confidential?
Yes, the form contains confidential patient information.
Can I share this PDF with others?
Absolutely, you can share the PDF after editing.
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