Form Nofr002 - Texas Standard Prior Authorization Request Form For Prescription Drug Benefits Page 3

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S
VII — P
D
I
ECTION
RESCRIPTION
EVICE
NFORMATION
Requested Device Name:
Expected Duration of Use:
HCPCS Code (If applicable):
S
VIII — P
C
I
ECTION
ATIENT
LINICAL
NFORMATION
Patient’s diagnosis related to this request:
ICD Version:
ICD Code:
(Provide the following information to the best of your knowledge)
Drugs patient has taken for this diagnosis:
Dates Started and Stopped
Describe Response, Reason
Drug Name
Strength Frequency
or Approximate Duration
for Failure, or Allergy
Drug Allergies:
Height (if applicable): Weight (if applicable):
Relevant laboratory values and dates (attach or list below):
Date
Test
Value
S
IX ― J
(S
I
P
S
IX)
ECTION
USTIFICATION
EE
NSTRUCTION
AGE
ECTION
NOFR002 | 0415
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Parent category: Medical
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