Form Gl2248 - Group Benefits Prior Authorization - Botox (Onabotulinumtoxina) Specialty Drug - 2016

Download a blank fillable Form Gl2248 - Group Benefits Prior Authorization - Botox (Onabotulinumtoxina) Specialty Drug - 2016 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 Gl2248 - Group Benefits Prior Authorization - Botox (Onabotulinumtoxina) Specialty Drug - 2016 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

GROUP BENEFITS
PRIOR AUTHORIZATION FORM
BOTOX
(OnabotulinumtoxinA) SPECIALTY DRUG
®
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? _________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
If diagnosed condition is hyperhidrosis, please indicate affected area.________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
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
GL2248 (03/16)
1920 COLLEGE AVENUE REGINA SK S4P 1C4
PG 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go