Fidelis Medication Prior Authorization Form

Use a Fidelis Medication Prior Authorization Form template to make your document workflow more streamlined.

DOB Age Height Weight Sex Prescriber name Specialty Contact Person Phone number Ext Fax County Injectable Medications J code Only Requested dates of Service J Code Units Requested FACILITY NAME Tax ID /NPI Medication Requested strength route frequency duration and quantity MUST BE INCLUDED TO AVOID DELAYS Current Diagnosis and Other Significant Medical history Relevant lab results scans x-rays etc* that support use of therapy or verify absence of contraindications adverse drug events. Attach.

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Video instructions and help with filling out and completing Fidelis Medication Prior Authorization Form

Find a suitable template on the Internet. Read all the field labels carefully. Start filling out the blanks according to the instructions: