Form Gl2429 - Group Benefits Prior Authorization - Tecfidera - 2014

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GROUP BENEFITS
PRIOR AUTHORIZATION FORM
TECFIDERA
®
INSTRUCTIONS
Mail: Co-operators Life Insurance Company
Extended Health Care Claims
1920 College Avenue
Regina, SK S4P 1C4
Fax:
(306) 761-7101
PART 1 - PATIENT INFORMATION
Group __________________________________
Account _______________________________________ Certificate _______________________________________
Plan Member _____________________________________________________________ ______ ___________________________________________________________
First Name
Initial
Last Name
Patient ___________________________________________________________________ ______ ___________________________________________________________
First Name
Initial
Last Name
Address _______________________________________________________ _________________________________________________ _______ __________________
Street
City
Province
Postal Code
Date of Birth ____________________________
Relationship to Plan Member _________________________________________________________________________
MMM/DD/YYYY
PART 2 - PHYSICIAN INFORMATION
Physician ______________________________________ ______ _______________________________________
Specialty ____________________________________
First Name
Initial
Last Name
Address _______________________________________________________ _________________________________________________ _______ __________________
Street
City
Province
Postal Code
Telephone Number ( ________ ) __________________________ Fax Number ( ________ ) __________________________
Name of Requested Drug _________________________________________________ DIN _________________________
Strength ___________________________
Expected Duration of Therapy _____________________________________________ Anticipated Monthly Cost $ ___________________
Diagnosis and Stage of Disease _________________________________________________________________________________________________________________
Please list all medications and/or therapies that have been used to treat this condition, including strength of drug, frequency of dosing and duration of each treatment.
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
What was the result of this treatment? ___________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
Expanded disability status scale (EDSS) score at time of diagnosis ___________________________________________________________________________________
Current Score ________________________________________________________________________________________________________________________________
I hereby certify that the information provided in this request is true, complete and accurate.
Physician Signature _________________________________________________________________________________ Date ___________________________________
MMM/DD/YYYY
PART 3 - PATIENT/GUARDIAN AUTHORIZATION
Co-operators Life Insurance Company Privacy Statement
Co-operators Life Insurance Company is committed to protecting the privacy, confidentiality, accuracy and security
of the personal information that it collects, uses, retains and discloses in the course of conducting business.
I authorize Co-operators Life Insurance Company (a) to use the personal information disclosed on this form, and any other personal information known to Co-operators Life
Insurance Company regarding the above-named patient, for the purpose of assessing this prior authorization request and any related claim and administering the benefit
plan under which any such claim is made, and (b) to contact, and to obtain any such personal information from and to disclose any such personal information to,
any physician, pharmacist or other health care professional having knowledge of such patient’s health relevant to this request and any related claim.
I hereby certify that the information provided in this request is true, complete and accurate.
Patient/Legal Guardian Name ________________________________________________________________ Telephone Number ( _______) _______________________
Signature of Patient/Legal Guardian _____________________________________________________________________
Date _________________________________
MMM/DD/YYYY
CO-OPERATORS LIFE INSURANCE COMPANY
GL2429 (11/14)
1920 COLLEGE AVENUE REGINA SK S4P 1C4
PG 1 of 1

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