Prior Authorization Request Form
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1Complete this form and fax it to 1-866-683-5631.
PRIOR AUTHORIZATION
For questions, please call 1-877-391-5921.
REQUEST
Date of request *
/
/
*Required items. Please write only in designated areas.
Member Information
Member ID*
Last Name
/
/
Date of Birth*
First Name
Ordering Physician
NPI*
-
-
Fax Number*
Contact Number*
TPI*
-
-
Tax ID*
Contact Name / Requestor
Last Name, First Initial
Medication Dispensing
Administering MD Office
Other Pharmacy
(other pharmacy must be within SHP network & have below completed)
Caremark
NPI*
-
-
Fax Number*
-
-
Contact Number*
Address
Medication Shipping Location
Physician's office
Member's address:
Address: _______________________________________
City, St Zip code: ________________________________
Phone number: __________________________________
Insurance Information
Primary Insurance: ____________________________ ID#: ______________________ Phone#: _________________
Secondary Insurance: __________________________ ID#: ______________________ Phone#: _________________
Clinical Review
Procedure codes:
Procedure code/CPT, HCPCS* modifier
J code
NDC
/
/
Start Date*
Diagnosis:
/
/
End Date*
Referring Diagnosis Code*
Units/Visits*
Day
/
/
Week
Date of Diagnosis.
Please include any diagnostic clinicals such as labs, radiology, exams, etc
Month
to support diagnosis. For Chemotherapy Medication Requests, please include Chemotherapy Regimen and Anticipated Dates of Service Requested.
'X' Indicates clinicals or plan of care attached.
Medication Requested
Medication Name
Strength
Dose
Quantity
Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)
____________________________________________________
_________________________________
Signature of Requesting Physician (required)
Date
Urgent Request -
By checking this box, I certify that this is an urgent request for medically necessary treatment, which must be treated within 24 hours.
Superior requires that certain services be approved before the service is rendered. Please refer to the SHP website,
for the most current full listing of authorized procedures and services. Note that an
authorization is not a guarentee of payment and is subject to utilization management review, benefits and eligibility.
SHP_20151122B
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Parent category: Medical