Medicare Prior Authorization Form

Medicare Prior Authorization Form

Please complete this Medicare Prior Authorization Form to request approval for medical services, treatments, or prescriptions under Medicare coverage.

Patient Information

Patient Name

    Date of Birth

      Phone number

        Email

          Member ID Number

          Sex

            • Male

            • Female

            Address

              Prescriber Information

              Prescriber Name

                NPI Number

                Address

                  Office Phone number

                    Office Fax Number

                    Contact Person Name

                    Medical Information

                    Medication

                    Strength & Root of Administration

                    Frequency

                      Is this a new prescription

                      Therapy Initiated Date

                        Expected Length of the Therapy

                        Qty

                        Height/Weight

                        Drug Allergies

                        Diagnosis

                        Rationale for Exception Request

                        Please select any of these applicable

                          • Alternate drug(s) contraindicated or previously tried, but with adverse outcome (e.g., 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

                          Upload Relevant Documents

                          I, the undersigned, request for

                          • Expedited review (24 hours)

                          • Other

                          Date: Date

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