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
Member ID Number
Sex
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Male
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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
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Alternate drug(s) contraindicated or previously tried, but with adverse outcome (e.g., toxicity, allergy, or therapeutic failure).
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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.
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Medical need for different dosage form and/or higher dosage.
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Request for formulary tier exception
Upload Relevant Documents
I, the undersigned, request for
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Expedited review (24 hours)
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Other
Date:
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