Medication Prior Authorization Request Form

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Medication Prior Authorization Request Form
*
*
Your request cannot be processed without complete information this includes provider specialty and address
Member Name:
Provider name:
Member ID:
Address:
Address:
Phone:
Phone:
Fax :
Date of Birth:
Specialty:
Medication:
Strength:
Directions for use:
Diagnosis*:
Date patient started medication:
Name of specific meds. tried and failed:
(Patient chart notes will be requested if further documentation is necessary)
Reason For Non-Formulary Request.
Requesting Physician’s signature:
Date:
Additional notes:
To Prescriber- Complete ENTIRE form, SIGN and return to:
Prescription Solutions
3515 Harbor Blvd.
Costa Mesa, CA 92626
Phone: 1-800-711-4555
Fax: 1-800-527-0531
***Please call to expedite your request***
11/13/2007

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