Prior Authorization Request Form
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1Ohio Medicaid Managed Care
Prior Authorization Request Form
AMERIGROUP
Buckeye Community Health Plan
CareSource Ohio
Molina Healthcare of Ohio
FAX: 800-359-5781
FAX: 866-399-0929
FAX: 866-930-0019
FAX: 800-961-5160
Phone: 800-454-3730
Phone: 866-399-0928
Phone: 800-488-0134
Phone: 800-642-4168
Paramount
Unitedhealthcare Community Plan
Wellcare
FAX: 419-887-2028
FAX: 866-940-7328
FAX: 877-277-6892
Phone: 800-891-2520
Phone: 800-310-6826
Phone: 800-678-3184
Patient Information
Patient Name
DOB
Date
Patient ID #
Sex
Medication Allergies
Pharmacy
Pharmacy Phone
For Injectables Only: Facility Name
For Injectables Only: Facility NPI #
Provider Information
Prescriber Name
NPI #
DEA #
Prescriber Specialty
Prescriber Address
Office Fax
Phone
Office Contact Name
Medication Requested
Drug Name
Strength
Dose
Directions (Sig)
Duration :
Quantity
Refills
Diagnosis
Days: ______ Months: ______
Is the Patient currently treated on this medication?
Yes; How Long
No
Patient Previous Medication(s) Relevent to this Request*
Please indicate previous treatment and outcomes below
Drug Name
Strength
Dose
Directions
Duration & Reason for Discontinuation
1
2
3
4
5
Relevant Medical Rationale for Request/Additional Clinical Information (Including diagnostic studies and lab results)*
Provider Signature
Date
*In order to process this request, please complete all boxes completely and attached relevant notes when appropriate.
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Parent category: Medical