Medicare Prior Authorization Form Template

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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