Prior Authorization Form - Specialty Drug - New Hamphire Healthy Families

Download a blank fillable Prior Authorization Form - Specialty Drug - New Hamphire Healthy Families 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 Prior Authorization Form - Specialty Drug - New Hamphire Healthy Families 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.

Send To:

AcariaHealth

Date: ____________________

Date Medication Required:_____________________

Ship to:

Physician

Patient’s Home

Other __________

Phone: (855) 535-1815

Prior Authorization Form

Fax: (855) 217-0926

Specialty Drug

Patient Name: ___________________________________________________

Physician Name: _______________________________________________

Address: _______________________________________________________

State Lic #______________________ DEA # ________________________

City: ________________________________State: _______Zip:____________

NPI # _________________________ Specialty: _____________________

Home Phone: (___________) ___________ - _________________________

Practice Name/Hospital: _________________________________________

Work Phone: (_______) _____________ - _________________________

Address: _____________________________________________________

Cell Phone: (__________) _____________ - _________________________

City: __________________________ State: ________ Zip: ____________

Patient Soc. Sec #: _________________ Allergies:_______________________

Physician’s Ph: (__________) ____________ - ______________________

Date of Birth: ___/___/___ Sex:

Male

Female

Weight _____

Physician’s Fax: (__________) ____________ - _____________________

lbs

Height: _______ BSA: ________ m²

See attached demographic sheet

Nurse/Key Office Contact: ________________________________________

INSURANCE INFORMATION (Complete or Attach Copies of cards)

Primary Insurance:__________________

Secondary Insurance:________________

Rx Card (PBM):_____________________

Cardholder First Name: ______________

City:______________State:___________

PBM BIN: ________________________

Last Name: _______________________

Plan #: ___________________________

City:______________State:___________

Employer: ________________________

Group #: _________________________

ID #: ____________________________

Phone: (______) ________-__________

Group #: _________________________

DIAGNOSIS (Required)

What is the ICD 9 / ICD 10 code? ____________________________

PATIENT EVALUATION

Is the member currently treated with this medication?

Yes; if yes, please continue

No; if no, please continue to question #4

2. How long has the patient been on treated with this medication: ______________

years

months

3. Has the patient had a positive outcome?

Yes

4. Please indicate previous treatments and outcomes?

Drug Name (include strength and dosage)

Dates of Therapy

Reason for Discontinuation

NOTE: confirmation of use will be made from member history on file; prior use of preferred drugs is part of the exception criteria

Please state Rationale for Request / Pertinent Clinical Information (Required for all prior authorizations)

**NOTE: We can NOT make a decision without a copy of pertinent lab results and/or the current clinical progress notes - Thank You**

MEDICATION

STRENGTH

DIRECTIONS

QUANTITY

REFILLS

Physician’s Signature: ____________________________________

Date____/_____/____

DAW (Dispense as Written

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under

applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to

disposal of the transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.