Group Benefits
prior AutHoriZAtion forM
XolAir
®
instructions
Mail: C o-operators Life Insurance Company
Extended Health Care Claims
1920 College Avenue
Regina, SK S4P 1C4
Fax: (306) 761-7101
pArt 1 - pAtient inforMAtion
Group _ _________________________________ Account _______________________________________ Certificate _____________________________________
Plan Member ___________________________________________________________ _______ ________________________________________________________
First Name
Initial
Last Name
Patient _________________________________________________________________ _______ ________________________________________________________
First Name
Initial
Last Name
Address _______________________________________________________ ___________________________________________ ___________ _______________
Street
City
Province
Postal Code
Date of Birth ____________________________ Relationship to Plan Member _ ______________________________________________________________________
MMM/DD/YYYY
pArt 2 - pHysiciAn inforMAtion
Physician ____________________________________ _______ ______________________________________ Specialty _ _________________________________
First Name
Initial
Last Name
Address _______________________________________________________ ___________________________________________ ___________ _______________
Street
City
Province
Postal Code
Telephone Number ( ________ ) __________________________ Fax Number ( ________ ) _ _________________________
Name of Requested Drug _________________________________________________ DIN _________________________ Strength _________________________
Expected Duration of Therapy _____________________________________________ Anticipated Monthly Cost $ ___________________
Diagnosis and Stage of Disease _ ______________________________________________________________________________________________________________
Please list:
Previous medications and dosage used to treat this condition (including intermittent doses or oral steriods). _ ________________________________________________
___________________________________________________________________________________________________________________________________________
Date when these medications were first prescribed and duration of therapy at specific dosages. __________________________________________________________
___________________________________________________________________________________________________________________________________________
Length of treatment and results for each medication/therapy previously tried. __________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Dates of emergency room visits, if any in previous 36 months. _____________________________________________________________________________________
Dates of hospitalization, if any in previous 36 months. ____________________________________________________________________________________________
Date of intensive care unit admissions, if any in previous 36 months. ________________________________________________________________________________
Please provide copies of the most recent lung function tests and the positive skin tests or evidence of in vitro reactivity.
I hereby certify that the information provided in this request is true, complete and accurate.
Physician Signature _________________________________________________________________________________ Date _________________________________
MMM/DD/YYYY
pArt 3 - pAtient/GuArdiAn AutHoriZAtion
co-operators life insurance company privacy statement
Co-operators Life Insurance Company is committed to protecting the privacy, confidentiality, accuracy and security
of the personal information that it collects, uses, retains and discloses in the course of conducting business.
I authorize Co-operators Life Insurance Company (a) to use the personal information disclosed on this form, and any other personal information known to
Co-operators Life Insurance Company regarding the above-named patient, for the purpose of assessing this prior authorization request and any related claim and
administering the benefit plan under which any such claim is made, and (b) to contact, and to obtain any such personal information from and to disclose any such
personal information to, any physician, pharmacist or other health care professional having knowledge of such patient’s health relevant to this request and any
related claim.
I hereby certify that the information provided in this request is true, complete and accurate.
Patient/Legal Guardian Name _ _______________________________________________________________ Telephone Number ( _______) _____________________
Signature of Patient/Legal Guardian _____________________________________________________________________ Date _ ______________________________
MMM/DD/YYYY
Co-operators Life insuranCe Company
GL2251 (07/11)
1920 CoLLeGe avenue reGina sK
s4p 1C4
pG 1 of 1