Prior Authorization Request Form

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ADHD Medications in Children < 6 years of age
Prior Authorization Request Form
If the child is a ward of DCFS, has consent to prescribe this psychotropic medication been obtained from DCFS?
If not, the prescriber must obtain consent from DCFS using the Psychotropic Medication Request form at
before prescribing any psychotropic medications.
Fax completed form: 217-524-7264
Additional information: 800-252-8942
To check status: 800-642-7588
Patient Information:
Prescriber Information:
Name:______________________________________
Name:_________________________________________
DOB:_______________________________________
Phone:__________________Fax:___________________
Nine-Digit HFS ID Number:______________________
Specialty:______________________________________
Provider #: ______________________________________
Contact person for this request:
Name: ______________________________________ Phone: __________________Fax:____________________
Clinical Information
1. Medication requested:_________________________Dose__________________Frequency________________
2. Indication:_________________________________________________________________________________
3. Please list other psychiatric illnesses with which patient has been diagnosed:____________________________
____________________________________________________________________________________________
4.
Patient’s Weight:______(kg) Age:_____(yrs) Physician-level review will be initiated if patient is < 4 yrs old
5.
Please indicate settings where the patient’s symptoms are present:
Home: Yes No
Daycare/preschool: Yes No
 Patient does not attend daycare/ preschool
6.
Check ALL that apply.
 Inattention present for:  less than 6 months  greater than 6 months
 Hyperactivity-impulsivity present for:  less than 6 months  greater than 6 months
 Other behavioral symptoms (include duration) __________________________________________________
_________________________________________________________________________________________
7.
Does patient have any of the following? (Check ALL that apply) [Physician-level review will be initiated]
 Oppositional defiant disorder
 Conduct disorder
 Anxiety disorder
 Developmental delay
 Pervasive depression
 Dysphoric mood
 Uncontrolled anger
 Psychosis
8. Please list ALL previous drug and non-drug therapy (including psychosocial interventions) for ADHD (claims
history will also be used for medication list): ______________________________________________________
____________________________________________________________________________________________
9. Is patient being discharged from hospital or institution on this medication?  Yes
 No
Other Pertinent Information: _____________________________________________________________________
____________________________________________________________________________________________
A Child and Adolescent Behavior Health Consultation Program is now available for providers who wish to
consult with a child and adolescent psychiatrist regarding their patients. This service is available at no charge.
The hotline number is: 1-866-986-2778. The website is:
Prescriber or designee signature: ___________________________
Date: _______________
HFSWEB007

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