Prescription Drug Prior Authorization Request Form Page 2
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P
D
P
A
R
F
RESCRIPTION
RUG
RIOR
UTHORIZATION
EQUEST
ORM
Patient Name:
ID#:
Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is
important for the review, e.g. chart notes or lab data, to support the prior authorization request.
1. Has the patient tried any other medications for this condition?
YES (if yes, complete below)
NO
Medication/Therapy
Duration of Therapy
Response/Reason for Failure/Allergy
(Specify Drug Name and Dosage)
(Specify Dates)
2. List Diagnoses:
ICD-9/ICD-10:
3. Required clinical information - Please provide all relevant clinical information to support a prior authorization review.
Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if patient has any
contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed to establish diagnosis, or
evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier
exceptions) or required under state and federal laws.
Attachments
Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer,
Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the
information reported on this form.
I agree to be notified via fax of the prior authorization determination and/or need for additional information at the Prescriber fax listed above.
Prescriber Signature:
Date:
Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If
you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the
contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via
return FAX) and arrange for the return or destruction of these documents.
Plan Use Only:
Date of Decision:
Approved
Denied
Comments/Information Requested:
New 08/13
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Parent category: Medical