Fee-For-Service Medicaid Prior Authorization Reconsideration Request Form - Texas Medicaid/chip Vendor Drug Program

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Texas Medicaid/CHIP Vendor Drug Program
Texas Prior Authorization Call Center
Fee-For-Service Medicaid Prior Authorization Reconsideration Request Form
Forms submitted prior to a denied prior authorization are not reviewed.
Request date:
__________________________
Patient
Name:
___________________________________________________________________________
Medicaid ID#:
__________________________
Date of birth:
__________________________
Drug
Name of product requested:
_______________________________________________________________________________
Strength (mg):
____________
Quantity: ____________
Length of therapy on prescription (months): ____________
Frequency of dosing:
____________
Diagnosis:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Are you providing any supporting documentation as part of this reconsideration?
Yes
No
Physician
Name:
____________________________________________
License #:
__________________________
Address:
____________________________________________
NPI:
__________________________
____________________________________________
Phone:
__________________________
City:
_________________________
State: _______ Fax:
__________________________
By signature, the prescribing physician confirms the information provided is accurate.
Signature:
______________________________________________
Date:
__________________
Rev. 06/2014
Page 2 of 2
File: vdp_dur_parecn

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