Prior Authorization Request Form printable pdf download

The document(s) accompanying this transmission may contain confidential health

information that is legally privileged. This information is intended only for the use of the

individual or entity named below. The authorized recipient of this information is

prohibited from disclosing this information to any other party unless required to do so by

law or regulation.

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Street

If you are not the intended recipient, you are hereby notified that any disclosure,

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copying, distribution, or action taken in reliance on the contents of these documents is

Bloomington, MN 55439

strictly prohibited. If you have received this information in error, please notify the

PH # 1-800-417-8164

sender immediately and arrange for the return or destruction of these documents.

Prior Authorization Request Form

FAX to ESI: 800-357-9577

Please Note:

If the following information is NOT filled in completely, correctly or legibly,

the authorization review will be delayed.

Insurance Company______________________________________________________

Patients Prescription ID#________________________________________________________

Patient Full Name______________________________________________________________

Patient Date of Birth____________________________________________________________

Medication Requested___________________________________________________________

Quantity Requested ________________________________for _______________ days supply

Physician Name (please print clearly) ______________________________________________

Physician DEA number (required) ________________________________________________

Physician Address______________________________________________________________

Physician Phone________________________________________________________________

Physician Fax__________________________________________________________________

Diagnosis-Indication-Medical History (reason for use of this medication)

______________________________________________________________________________

Other Medications/Therapies Tried and Reason(s) for Failure_________________________

______________________________________________________________________________

_____________________________________ Date_______________

Physician Signature

Office Contact Person___________________________________________________________

Any further information pertaining to this drug request should be included and attached to this form.

Prior Authorization Request Form