PRIOR AUTHORIZATION FORM
GENERAL FORM
Incomplete forms may delay processing or result in an adverse
determination. FOR URGENT REQUESTS, please call 800-710-9341.
Phone: 1-800-710-9341
FAX BACK TO 318-214-4190
EXPEDITED REVIEW REQUESTED
PROVIDER INFORMATION
PATIENT INFORMATION
Provider Name
Provider NPI
Patient Name
Office Contact Person
Southern Scripts ID
Rx Group Number
Physician Address (Street, City, State, Zip)
Patient DOB
Patient Phone
Provider Specialty
Is fax secured?
Prescription #
Pharmacy
Yes
No
Provider Phone #
Provider Fax #
Diagnosis Code
Date of Diagnosis
CHECK ALL BOXES THAT APPLY. INCOMPLETE FORMS WILL BE DENIED.
Medication Name
Strength
Directions
Qty per month
New Medication
Ongoing Medication / Date Started ______________________
Has the patient shown improvement while on therapy?
Yes
No
Physician’s Office, Clinic, Hospital, or Facility
1. Place of administration:
Patient Home
2. Please indicate the condition being treated:
3. Is this treatment acute or chronic?
4. Severity of Disease:
Mild
Moderate
Severe
5. Anticipated Length of Therapy:
6. Does the patient have evidence of failure, intolerance or contraindication, or inadequate response to
conventional therapies?
Yes
No
If yes, please provide detail (name of medications, doses, and dates of trials):
7. Other pertinent information to support this medication is medically necessary (please attached additional
information such as progress note if needed):
I certify that, to the best of my knowledge, the information above is accurate.
Prescriber’s Signature Required:___________________________________Date:______________________
SOUTHERN SCRIPTS ONLY:
Please Return Completed Form To: Fax number: (318) 214-4190
7/9/2014