Form Gl2249 - Group Benefits Prior Authorization - Xolair - 2011

Download a blank fillable Form Gl2249 - Group Benefits Prior Authorization - Xolair - 2011 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 Form Gl2249 - Group Benefits Prior Authorization - Xolair - 2011 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.

Group Benefits

prior AutHoriZAtion forM

forteo

instructions

Mail: C o-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 provide copies of all serial bone density studies (preferably performed in the same laboratory).

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? _________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

List all fractures and date of occurrence of each. _________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

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

GL2249 (07/11)

1920 CoLLeGe avenue reGina sK

s4p 1C4

pG 1 of 1