Medicare Prior Authorization Form
Patient Information
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Member ID Number
Sex
Female
Male
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prescriber Information
Prescriber Name
First Name
Last Name
NPI Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
Office Fax Number
Contact Person Name
First Name
Last Name
Medical Information
Medication
Strength & Root of Administration
Frequency
Is this a new prescription
Yes
No
Therapy Initiated Date
-
Month
-
Day
Year
Date
Expected Length of the Therapy
Qty
Height/Weight
Drug Allergies
Diagnosis
Rationale for Exception Request
Please select if any of these applicable
Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure).
Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change.
Medical need for different dosage form and/or higher dosage.
Request for formulary tier exception.
Other
Please Explain in Detail
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of
Request for Expedited Review
I, the undersigned, request for
Expedited review (24 hours)
Other
Date
-
Month
-
Day
Year
Date
Signature
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Submit
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