Prescription Drug Prior Authorization Request Form
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P
D
P
A
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RESCRIPTION
RUG
RIOR
UTHORIZATION
EQUEST
ORM
Plan/Medical Group Name: ________________________________
Plan/Medical Group Phone#: (_______)
Plan/Medical Group Fax#: (_______)
____
Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is
important for the review, e.g. chart notes or lab data, to support the prior authorization request.
Patient Information: This must be filled out completely to ensure HIPAA compliance
First Name:
Last Name:
MI:
Phone Number:
Address:
City:
State:
Zip Code:
Date of Birth:
Male
Circle unit of measure
Allergies:
Female
Height (in/cm): ______Weight (lb/kg):______
Patient’s Authorized Representative (if applicable):
Authorized Representative Phone Number:
Insurance Information
Primary Insurance Name:
Patient ID Number:
Secondary Insurance Name:
Patient ID Number:
Prescriber Information
First Name:
Last Name:
Specialty:
Address:
City:
State:
Zip Code:
Requestor (if different than prescriber):
Office Contact Person:
NPI Number (individual):
Phone Number:
DEA Number (if required):
Fax Number (in HIPAA compliant area):
Email Address:
Medication / Medical and Dispensing Information
Medication Name:
New Therapy
Renewal
If Renewal: Date Therapy Initiated:
Duration of Therapy (specific dates):
How did the patient receive the medication?
Paid under Insurance Name:
Prior Auth Number (if known):
Other (explain):
Dose/Strength:
Frequency:
Length of Therapy/#Refills:
Quantity:
Administration:
Oral/SL
Topical
Injection
IV
Other:
Administration Location:
Patient’s Home
Long Term Care
Physician’s Office
Home Care Agency
Other (explain):
Ambulatory Infusion Center
Outpatient Hospital Care
New 08/13
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Parent category: Medical