ࡱ>     O 6bjbjȽ .ߢeߢe7,,,,q:q:q:q:q::::8:$;d: g"E>|DDDDFN)HHdf f f f f f f$/ik.fq:QIF"FQIQI.fq:q:DDfUQUQUQQIDq:Dq:DfUQQIfUQUQTUD0hoKUef0 gUlKl4UUlq:UQIQIUQQIQIQIQIQI.f.f]NQIQIQI gQIQIQIQIlQIQIQIQIQIQIQIQIQI,, 79:  Pharmacy Information Authorization Org 1.  FORMTEXT     Authorization Type 2.  FORMTEXT      Client InformationName3.  FORMTEXT      Client ID4.  FORMTEXT      5. Reference Auth #6.  FORMTEXT      Provider InformationPharmacy NPI #7.  FORMTEXT      Pharmacy Fax #8.  FORMTEXT      Prescriber NPI #9.  FORMTEXT      Prescriber Specialty 10.  FORMTEXT      Prescriber Phone #11.  FORMTEXT      Prescriber Fax #12.  FORMTEXT      Date of Fill: 13.  FORMTEXT       Dispense as Written (Yes/No)14.  FORMTEXT     Service Request InformationDrug Name, Strength and Form: 15.  FORMTEXT      Actual per unit cost 16.  FORMTEXT      AWP per unit cost 17.  FORMTEXT      18. RX#  FORMTEXT      19. Wholesaler  FORMTEXT      20. Code Qualifier21. Product ID22. Qty 23. Days Supply24.25. Directions for Use (SIG)26. Prod Select Cd FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT    FORMTEXT       FORMTEXT     FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT    Medical Information Diagnosis Code27.  FORMTEXT      Diagnosis name28.  FORMTEXT      Patient Residence29.  FORMTEXT    30. Comments:  FORMTEXT      Please Fax this form and any supporting documents to 1-866-668-1214.The material in this facsimile transmission is intended only for the use of the individual to who it is addressed and may contain information that is confidential, privileged, and exempt from disclosure under applicable law. HIPAA Compliance: Unless otherwise authorized in writing by the patient, protected health information will only be used to provide treatment, to seek insurance payment, or to perform other specific health care operations.  FIELDNAMEACTIONALL FIELDS MUST BE TYPED.1Org: (Required) Enter the corresponding number indicating whether this is a request for Authorization or a request for reimbursement Rate Adjustment for prescriptions NOT signed Dispense As Written: 512: Pharmacy Authorization 522: Pharmacy Rates2Authorization Type: (Required)Indicate whether the request is an update to an existing authorization, or a new request for the client: 1: New 2: Update3Name: (Required)Enter the last name, first name, and middle initial of the client you are requesting authorization for. 4Client ID: (Required)Enter the Client ID from ID card (9 numbers followed by WA.)5N/A Leave blank.6Reference Auth #: (Required for Updates)If requesting a change to or extension of an existing authorization, please enter the previous authorization number in this field.7Pharmacy NPI #: (Required)The unique 10 digit numeric identification number that has been assigned to the Pharmacy by CMS.8Pharmacy Fax#: (Required)The Pharmacys fax number, excluding dashes or spaces. (123)123-1234 would be entered as 1231231234.9Prescriber NPI #: (Required)The unique 10 digit numeric identification number that has been assigned to the Prescriber by CMS.10Prescriber Specialty:The specialty practice of the prescriber.11Prescriber Phone #: (Required)The prescribing providers phone number, excluding dashes or spaces. (123)123-1234 would be entered as 1231231234.12Prescriber Fax#: (Required)The prescribing providers fax number, excluding dashes or spaces. (123)123-1234 would be entered as 1231231234.13Date of Fill: (Required)If the authorization request is for a prescription that has already been dispensed to the client, enter date of fill. Otherwise, enter date of authorization request submission.14Dispense as Written: (Yes/No)Enter YES if the prescription was signed Dispense as Written. 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Only one NDC can be requested per form. Please disregard additional lines available on the form (reserved for later use).22Quantity: (Required) The quantity of product requested for this fill.23Days Supply: (Required)The minimum number of days that the requested quantity would be expected to last according to the prescribed directions for use.24N/A Leave blank.25Directions for Use (SIG): (Required)The prescribed directions for use for this fill.26Prod Select Code: (Required if the prescription is signed Dispense as Written)Enter 1 f the prescription is signed Dispense As Written. Otherwise leave blank.27Diagnosis Code: If known, enter appropriate ICD-10 diagnosis code for condition being treated.28Diagnosis name:Short description of the diagnosis the requested product will be used to treat.29Patient Residence: Enter the corresponding code for the client s living arrangement: 01  Client does not reside in a skilled nursing facility. 02  Client resides in a skilled nursing facility. 11  Client is part of a hospice program, but the requested medication is not related to the client s terminal illness.30Comments: Enter any additional information necessary to explain the medical necessity for the requested fill. Note: A confirmation fax will be sent to you if your fax number can be identified by caller ID. The receiving fax must recognize the number the fax has been sent from.     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