Fillable Prior Authorization Form printable pdf download

Prior Authorization Form

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LDI Integrated Pharmacy Services

701 Emerson Road, Suite 301

Creve Coeur, MO 63141

Phone (314)6523121 Fax (877)5044551

Prior Authorization Form

Date:__________________

Complete the information below, sign and date. Please FAX completed forms to LDI at (877)504-4551. If the Plan's coverage conditions are met, coverage will be

authorized. Any questions please contact LDI at (866)-516-3121

Patient Information

Last Name:

First Name:

DOB:

Sex:

Prescriber Information

Prescriber Name:

DEA/NPI:

Phone:

Fax:

Prescriber Specialty:

Medication:________________________________________________

Dosage

Qty:

Directions:

Diagnosis:

Is the patient a new start?

Yes

No If no, how long has the patient been on the current therapy?

Proposed length of treatment:

Please list other medications the patient has tried to treat this condition:

Please submit relevant chart notes and labs showing clinical need

for medication requested or evidence of continued efficacy.

Comments:

Information given on this form is accurate as of this date.

_____________________________________________

___________________

Prescriber or Authorized Signature

Date

I understand that LDI Integrated Pharmacy Services use or disclosure of individually identifiable health information, whether furnished by me or obtained by another source such as

medical providers, shall be in accordance with federal regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996).