Pha Wellness Medication Prior Authorization Form printable pdf download

Pha Wellness Medication Prior Authorization Form

PHA WELLNESS MEDICATION PRIOR AUTHORIZATION FORM

Some insurance companies require Prior Authorizations (PAs) for certain medications. Without

a prior authorization, your health insurance may not cover your medication, and you would

have to pay out of pocket. It usually takes approximately 30 minutes to fill out this form.

NOTE: By submitting this form you are giving us permission to release pertinent information to your pharmacy.

Once your completed form is received, we will process the prior authorization. Please allow your pharmacy one

week to process. If the request is not approved, please contact your insurance company to find out why.

PATIENT AND INSURANCE INFORMATION

Patient Name

____________________________

Patient Date of Birth:

____________________________

Name of Policy Holder:

____________________________

Policy Holder Date of Birth:

____________________________

Patient’s Relationship to Policy Holder: _______________________

Policy Holder’s Address:

____________________________

Patient Phone Number:

____________________________

INSURANCE/THIRD PARTY INFORMATION REQUESTING THE PA

Your insurance company or the third party that covers pharmacy medications (may be different than

your health insurance member ID)

Name (ex. Express Scripts/Cooportunity Health/etc.):______________________________

Cardholder ID: __________________________________________________________

Group Number: ______________________

Person Code:

_______________________

Relationship:

________________________

Phone:

________________________

FAX for Prior Authorizations: _____________________

Prior Authorization Number (6-10 digits): _______________________________________

*Please note your pharmacy-related insurance may require you to fill out additional paperwork or

forms for a PA, so it may be a good idea to reach out to them as well.

Page 1 of 3

Pha Wellness Medication Prior Authorization Form