Prior Authorization Form

Plan/Medical Group Name

Phone/Fax Number

Please enter a valid phone number.

Name

First NameLast Name

MI

Birth Date

MonthDayYear

Gender

MaleFemale

Circle unit of measure

Allergies

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Authorized Representative (if applicable)

First NameLast Name

Authorized Representative Phone Number

Please enter a valid phone number.

Primary Insurance Name

Patient ID Number

Secondary Insurance Name

Patient ID Number

Prescriber Name

First NameLast Name

Speciality

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Requestor (if different than prescriber)

First NameLast Name

Office Contact Person

First NameLast Name

NPI Number (individual)

DEA Number (if required)

Phone Number

Please enter a valid phone number.

Fax Number

in HIPAA compliant area

Email Address

example@example.com

Medication Name

Type

New TherapyRenewal

Date Therapy Initiated

Date

Duration of Therapy

Specific Dates

How did the patient receive the medication?

Paid under insuranceOther

Name

Prior Authorization Number

If known

Dose / Strength

Frequency

Length of Therapy / #Refills

Quantity

Administration

Administration Location

Has the patient tried any other medications for this condition?

YesNo

Other Medications

List Diagnosis

ICD-9/ICD-10

Required Clinical Information

Please provide all relevant clinical information to support a prior authorization review.

Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if patient has any contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed to establish diagnosis, or evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier
exceptions) or required under state and federal laws.

I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.

Prescriber Signature

Date

Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for the return or destruction of these documents.

Plan use only:

Date of Decision

Date

Status

ApprovedDenied

Comments/Information Requested

Prior Authorization Form

Patient Information

Insurance Information

Prescriber Information

Medication / Medical and Dispensing Information

Attestation