Caremark Prior Authorization Form printable pdf download

Caremark Prior Authorization Form

PRIOR AUTHORIZATION REQUEST FORM

**Please note that this form is to be completed by the prescribing physician. This form and its contents are permissible under HIPAA,

as the protected health information (PHI) contained in this letter is only being used for purposes related to the provision of treatment,

payment, and healthcare operations (TPO). HIPAA does not restrict the communication of PHI with providers for TPO related

purposes.

Date of Request________________

Case #_________________

Member Name

DOB

Member Identification Number

TPC

Physician Name

DEA# / Specialty

Physician Phone #

Physician Fax #

Medication / Dose Requested:

We have received your request for prior authorization for the patient and medication listed above. In

order to complete our review and make an appropriate determination, the following information will be

necessary:

Diagnosis: _____________________________________

ICD-9 Code: _________________

Previous medication treatment history:

_____________________________________________________________________________________________

Other relevant patient information:

____________________________________________________________

______________________________________________________________________________________________

Physician Signature: __________________________________________Date:____________

**Physician signature field must be completed. Requests will not be reviewed in the event that this field is incomplete.

**Please call 1-800-952-9684 for assistance in filling out this form. (Dr. office only). Most requests are processed within one business day

of receiving complete information. Some requests may, however, require more time to review.

COMPLETED FORMS MAY BE FAXED TO 1-800-230-0783

Caremark Prior Authorization Form