Form 61-211 - Prior Authorization Request Form (Page 2 of 2) in pdf

Form 61-211 - Prior Authorization Request Form Page 2

Page 2 of 2

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)

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.

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

Form 61-211

Form 61-211 - Prior Authorization Request Form Page 2