Free Prior Authorization Form Template
Prior Authorization Form
Please complete this Prior Authorization Form to request approval for medical treatments, services, or medications that require authorization from an insurance provider.
Name
Birth Date
Gender
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Male
-
Female
Circle Unit of Measurement
Height
Weight
Allergies
Phone number
Address
Insurance Information
Primary Insurance Name
Patient ID Number
Secondary Insurance Name
Patient ID Number
Prescriber Information
Prescriber Name
Specialty
Address
Medication/Medical and Dispensing Information
Medication Name
Type
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New Therapy
-
Renewal
How did the patient receive the medication?
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Paid under insurance
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Other
Dose/Strength
Frequency
Length of Therapy
Quantity
Administration
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Oral/SL
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Topical
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Injection
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Other
Administration Location
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Physician's Office
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Ambulatory Infusion Center
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Patient's Home
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Home Care Agency
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Outpatients Hospital Care
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Long Term Care
Has the patient tried any other medications for this condition?
List Diagnosis
Required Clinical Information
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 or required under state and federal laws.
Attestation
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 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 and arrange for the return or destruction of these documents.
Date of Decision
Status
-
Approved
-
Denied
Comments/Information Required
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