Humana Universal Fax Form For Drug Authorization

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Humana Clinical Pharmacy Review

1-877-486-2621 (Fax)

Universal fax form for drug authorization

Patient Information

Physician Information

Patient name:

Date of Birth:

Name:

TAX ID#:

Address

City

State

Zip code

Sex:

Home Phone:

Work Phone:

(

)

(

)

Subscriber ID#

Telephone: (

)

Fax: (

)

Address

City

State

Zip code

Physician Specialty (if applicable):

Medication administered (if injectable):

Physician office

Will physician supply the medication?

Yes

Physician signature (required):

Date:

Patient’s home

Other _____________________________________________

Diagnosis and Medical Information

State from which you are requesting this medication (required):

Is this a reauthorization?

Yes

Diagnosis:

Therapeutic alternatives previously used (required):

_________________________________________

ICD-9 Code:

J-Code:

Please list outcomes from previous treatment:

_________________________________________

Please provide any medical information which may support approval:

Note: Medications may be subject to a quantity limitation sufficient for a 30 day supply per fill based on FDA approved

dosages.

Medication and Dose Requested

Medication requested:

Dosage:

Sig:

The information contained in the document is confidential. This information is intended only for the use of the individual or entity named above. If you are not the intended recipient of this information, you

are hereby notified that any disclosure, copying or distribution of this information or the taking of any action in reliance on this information is strictly prohibited. If you have received this message in error

please immediately notify the sender by telephone to arrange for its return.

Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what medications are

appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions.

Please note any information left blank or illegible may delay the review process

JC/DM 11/05 (W) eForms