Form Gl2250 - Group Benefits Prior Authorization - Growth Hormones - 2014

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GROUP BENEFITS
PRIOR AUTHORIZATION FORM
GROWTH HORMONES
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? ___________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
Please provide details of laboratory tests carried out, and include normal values by age and gender for the tests carried out in that laboratory. ____________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
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
GL2250 (10/14)
1920 COLLEGE AVENUE REGINA SK S4P 1C4
PG 1 of 1

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