Prior Authorization Worksheet For Prescribers Clinical Drug Review Program - New York State Medicaid Program Page 2
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1
2
3NEW YORK STATE MEDICAID PROGRAM
PRIOR AUTHORIZATION WOR SHEET FOR PRESCRIBERS
K
CLINICAL DRUG REVIEW PROGRAM
Prior Authorization Call Line 1- 877- 309-9493
RECIPIENT IN
FORMAT
ION
Recipient Name:
Street:
Recipient Medicaid ID#:
C
ity:
State:
Zip:
(2 letters, 5 numbers, 1 letter)
PRESCRIBER INFORMATION
Prescriber Name:
C
ontact Person:
Prescriber ID Number (MMIS) __ __ __ __ __ __ __ __
Street:
OR License
NYS Physician /PA/Resident: 0 0 __ __ __ __ __ __
NYS O
ptometrist: U __ __ __ __ __ __ or V __ __ __ __
City:
State:
Zip:
__ __
NYS Nurse Practitioner/Midwife: F __ _
_ __ __ __
NYS Dentist:
0 0 0 __ __ __ __ __
Office Phone#:
Office Fax #:
NYS
Podiatrist: 0 0 0 0 __ __ __ __
OR
Out-of-State License: __ __ __ __ __ __ __ __
(Use your state abbreviation in t
he first two spaces.)
DIAGNOSIS AND MEDICAL INFORMATION
Drug Name:
Strength and Route of Administration:
Frequency:
New Prescription OR
Expected Length of Therapy:
Qty:
Date Therapy Initiated:
Height/Weight:
Drug Allergies:
Diagnosis:
Prescriber’s Signature:
Date:
CLINICAL CRITERIA S
PECIFIC TO A CDRP DRUG MU
ST BE COMPLETED
FOR PRIOR AUTHORIZATION
Clinical criteria relevant to each specific CDRP drug is available on the proceeding pages, and must be completed
b
efore prior authorization will be given.
PRIOR AUTHORIZATION NUMBER
Prior Authorization Number (11 digits): __ __ __ __ __ __ __ __ __ __ __
The attached mandatory Clinical Criteria must be completed
before a prior authorization will be issued.
DO NOT FAX THIS FORM
For billing questions, call 1-800-343-9000
For clinical concerns o
r Clinical Drug Review Program questions, visit
w
ww.nyhealth.gov
and
or call 1-877-309-9493
For Medicaid pharmacy policy and operations questions, call (518) 486-3209
Revised 9/06
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