Pha Wellness Medication Prior Authorization Form Page 2

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PHARMACY INFORMATION
Please   c ontact   y our   p harmacy   t o   o btain   t he   f ollowing   i nformation:  
 
Pharmacy where medication request was sent: ____________________________
Store Number: ________________________________________________________
Store Address: ________________________________________________________
Phone: _______________________________________________________________
Fax: __________________________________________________________________
Pharmacy National Provider ID (NPI): _____________________________________
Prescription (RX) number:_________________________
National Drug Code (NDC) number for the medication: _________________
*Please let the pharmacist know whether you are requesting a brand name product versus generic to ensure you
get the right in NDC number
MEDICATIONS
If   y ou   n eed   a dditional   s pace,   p lease   a ttach   a nother   p age.    
PRIOR MEDIC ATION(S)
Please   l ist   m ental   h ealth-­‐related   m edications   y ou   h ave   u sed   i n   t he   p ast.    
Medication Name
Dosage
Start Date
1
End Date
If ended, why was
the medication
stopped?
Medication Name
Dosage
Start Date
2
End Date
If ended, why was
the medication
stopped?
Medication Name
Dosage
Start Date
3
End Date
If ended, why was
the medication
stopped?
 
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