Xenical Prior Authorization Form

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GROUP INSURANCE
According to your province of residence, please submit form to:
PRIOR AUTHORIZATION FORM
Quebec
Ontario, Atlantic and Western Provinces
XENICAL
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
The purpose of this form is to obtain information required to assess your claim for Xenical. Xenical must satisfy the criteria for coverage under
your plan.
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
We are in the process of reviewing a request received for Xenical prescribed for the above patient. Please provide us with the following
information.
1.
What is the patient’s Body Mass Index?
_____________________________________________________________________________________________________________________
2.
What are the patient’s current weight and height?
_________________________________________________________________________________________________________
3.
Has the patient been diagnosed with any specific illness(es) that are adversely affected by unhealthy body weight?
No
Yes
If yes, please list these conditions.
_____________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________
4.
If diabetic, please specify the type:
___________________________________________________________________________________________________________________________
5.
What is the expected duration of the treatment?
___________________________________________________________________________________________________________
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 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
F54-860A(12-07)

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