Antipsychotic Medications Prior Authorization Of Benefits (Pab) Form

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CONTAINS CONFIDENTIAL PATIENT INFORMATION

Antipsychotic Medications

Prior Authorization of Benefits (PAB) Form

Complete form in its entirety and fax to:

Prior Authorization of Benefits Center at (800) 601- 4829

1. PATIENT INFORMATION

2. PHYSICIAN INFORMATION

Patient Name: _____________________________

Prescribing Physician: __________________________

Patient ID #:

_____________________________

Physician Address:

__________________________

Patient DOB:

_____________________________

Physician Phone #:

__________________________

Date of Rx:

____________________________

Physician Fax #:

__________________________

Patient Phone #:____________________________

Physician Specialty:

__________________________

Patient Email Address: _______________________

Physician DEA:

__________________________

Physician NPI #.

__________________________

Physician Email Address: _______________________

3. MEDICATION

4. STRENGTH

5. QUANTITY PER 30 DAYS

____________________________

_________________________

Specify: _____________________

6. DIAGNOSIS: ___________________________________________________________________________________

7. APPROVAL CRITERIA: CHECK ALL BOXES THAT APPLY

NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this

request.

Please indicate patient’s age: ______________________

□

Yes

Patient has had an assessment from a child psychiatrist, pediatric neurologist, general psychiatrist,

developmental behavioral pediatrician, or neurologist

8. PHYSICIAN SIGNATURE

____________________________________________

______________________________________

Prescriber or Authorized Signature

Date

Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what

medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting provider

certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.

Note: Payment is subject to member eligibility. Authorization does not guarantee payment.

The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only for

the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party

unless required to do so by law or regulation.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these

documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction

of these documents.

Antipsychotic Medications NTL PAB Fax Form 12.17.14.doc