Prior Authorization Form

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

      • 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

              • New Therapy

              • Renewal

              How did the patient receive the medication?

                • Paid under insurance

                • Other

                Dose/Strength

                Frequency

                Length of Therapy

                Quantity

                Administration

                  • Oral/SL

                  • Topical

                  • Injection

                  • Other

                  Administration Location

                  • Physician's Office

                  • Ambulatory Infusion Center

                  • Patient's Home

                  • Home Care Agency

                  • Outpatients Hospital Care

                  • 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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