Molina Healthcare Of Florida Medication Prior Authorization / Exceptions Request Form

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Molina Healthcare of Florida
Medication Prior Authorization / Exceptions
Request Form
Fax form to: (866) 236-8531
To ensure a timely response, please fill out form completely and legibly. An incomplete form may be returned.
Please submit clinical information as needed to support medical necessity of the request. Requests will not
be processed if any of the following information is missing: member information, provider information or
clinical documentation (chart notes). For any questions, please contact Molina by phone at: (866) 472-4585.
Today’s Date:
Medicaid
Marketplace (Exchange Plans)
This option is reserved for routine/maintenance requests.
Standard Request
This option is reserved for life threatening conditions which may seriously
Expedited
jeopardize the life and health of the member.
(MD Signature Required)
MD Signature:
Member Information
Last Name:
First Name:
ID Number:
Date of Birth:
Provider Information
Name:
Specialty & NPI number:
Fax Number:
Phone Number:
Review Type:
Discharge Planning (please provide date of discharge
/
/
)
Initial Review
Reauthorization
(recent clinical documentation showing evidence of Clinical efficacy must be submitted)
1) Medication Requested:
(Include name, strength, directions and quantity)
2) ICD-10 Code/Diagnosis description for requested medication:
3) Previous formulary medication trial and failures:
(Length of treatment/outcome with dates must be supported in clinical
documentation (chart notes). Use of pharmaceutical samples cannot be accepted as justification.)
***********HIPAA Confidentiality Notice*************
The document inside this electronic transmission contains confidential information belonging to the sender 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 and is
required to destroy the information after its stated need has been fulfilled, unless otherwise required by law. 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 received this electronic
transmission in error, please notify the sender immediately to arrange for return.
Molina Healthcare of Florida
Rev. 02/2016

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