Industrial Alliance Prior Authorization Form

Download a blank fillable Industrial Alliance Prior Authorization Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Industrial Alliance Prior Authorization Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Print
GROUP INSURANCE
According to your province of residence, please submit form to:
PRIOR AUTHORIZATION FORM
Quebec
Ontario, Atlantic and Western Provinces
PO Box 800, Station Maison de la Poste
522 University Avenue, Suite 400
Montreal, Quebec H3B 3K5
Toronto, Ontario M5G 1Y7
Fax: 1 855 884-9811
Fax: 1 877 780-7247
This form is to obtain information required to assess your claim for a drug on the Industrial Alliance Prior Authorization list. The drug must
satisfy the criteria for coverage under your plan. In Quebec, if it is a drug covered under the RAMQ Exception Drug list, it must meet the
criteria for coverage under that program, as well.
PART 1 – MEMBER/PATIENT INFORMATION
Member name
_______________________________________________________________________________________________________________________________________________________
Policy no.
Certificate no.
Patient name (if different)
___________________________________________________________________________________________________________________________________________
Y
M
D
Relationship to plan member
Date of birth
________________________________________________________________________________
PART 2 – TO BE COMPLETED BY PHYSICIAN
1.
Drug name:
Daily dosage:
____________________________________________________________________________________
_______________________________________________
2.
What is the expected duration of the treatment?
___________________________________________________________________________________________________________
3.
Specify the medical condition warranting use of the aforementioned drug
_____________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
4.
Provide a brief overview of the patient’s current clinical status
___________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
5.
Provide a description of the previous treatment program and its results
________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
6.
Indicate where the medication will be administered
Home (self-administered)
Hospital
Private clinic
Other, specify
___________________________________________________________
7.
Are any alternative drug treatments available?
_____________________________________________________________________________________________________________
8.
Are there any other sources of funding available for this medication? (e.g.: Ministry of Health, special drug program, charitable
organization, etc.)
_______________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
9.
Is a specialist involved in the treatment?
Yes
No
If yes, please provide a copy of the consultation report.
10. Provide any additional information that supports the use of this drug for this patient
_________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
Physician’s last and first name
_____________________________________________________________________________________________________________________________________
Address
Postal code
_________________________________________________________________________________________________________________
Telephone
Fax
Email
__________________________________________________________________________________________________________________________________________________________________
General practitioner
Specialist
Other, specify
_______________________________________________________________________________________________
Y
M
D
X
Signature
Date
________________________________________________________________________________________
PART 3 – MEMBER CONFIRMATION/AUTHORIZATION
I agree that the statement included in this form will serve as a basis to review my own or my dependent’s drug claim.
If the drug claim being reviewed is for my dependent, I confirm that I have the authorization to discuss the information about him or her with
respect to the drug claim.
On behalf of myself and my dependent, I authorize my physician or healthcare provider to disclose and exchange with Industrial Alliance the
information requested in this form regarding the drug for myself or my dependent. I consent to the release of the information in this form to
Industrial Alliance, its employees, agents and reinsurers. If my Social Insurance Number is used as my identification number, I authorize its use
for the administration of my group benefits.
I AGREE that a photocopy of this Confirmation/Authorization shall be as valid as the original.
Y
M
D
X
Member’s signature
Date
____________________________________________________________________________________________________
Address
Postal code
_________________________________________________________________________________________________________________
Tel. home
Tel. work
Extension
F54-859A(12-07)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form F14 - Prior Authorization Form Form F14 - Prior Authorization Form Business
Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Business
Form 470 - Alabama Medicaid Pharmacy Smoking Cessation Prior Authorization Form Form 470 - Alabama Medicaid Pharmacy Smoking Cessation Prior Authorization Form Business
Form Dhmh 0514 - Hepatitis C Therapy Prior - Authorization Form Form Dhmh 0514 - Hepatitis C Therapy Prior - Authorization Form Legal
Form Pca18558 - Enzyme Replacement Therapy For Gaucher Disease Prior Authorization Form Form Pca18558 - Enzyme Replacement Therapy For Gaucher Disease Prior Authorization Form Business
Form Pca18563 - Immune Globulin (ivig And Scig) Prior Authorization Form Form Pca18563 - Immune Globulin (ivig And Scig) Prior Authorization Form Medical
Prior Authorization Form General Request Form - Express Scripts Prior Authorization Form General Request Form - Express Scripts Business
Prior Authorization Form Erythropoiesis Stimulating Agents Prior Authorization Form Erythropoiesis Stimulating Agents Business
Prior Authorization Form Psoriasis Agents Prior Authorization Form Psoriasis Agents Business
Prior Authorization Form - Priority Health Prior Authorization Form - Priority Health Business

Related Categories

Parent category: Medical
Download
Go