Form F14 - Prior Authorization Form

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Prior Authorization Form

General Request Form

This form is based on Express Scripts standard criteria and may not be

Fax completed form to 1-877-329-3760

applicable to all patients; certain plans and situations may require

additional information beyond what is specifically requested.

If this an URGENT request, please call 1-800-753-2851

Additional forms available:

Patient Information

Prescriber Information

Patient First Name: ______________________________

Prescriber Name: _________________________________

Prescriber DEA/NPI (required): ______________________

Patient Last Name: _______________________________

Prescriber Phone #: _______________________________

Patient ID#: _____________________________________

Prescriber Fax #: _________________________________

Patient DOB: ____________________________________

Prescriber Address: _______________________________

Patient Phone #: _________________________________

State: ________________ Zip Code: __________________

Diagnosis: _________________________________________ ICD Code: ________________________________________

Please indicate which drug and strength is being requested:

________________________________________________________________

Quantity Requested

for

days supply

___________________________________________

_________________________________________________

Other Medications/Therapies tried and reason(s) for failure and/or any other information the physician feels is important to the review:

__________________________________________________________________________________________

Prescriber Signature: __________________________________________Date: ____________________

Office Contact Name: ___________________________ Phone Number: __________________________

Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any

questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.

Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a

treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information

regarding benefits, conditions, limitations, and exclusions.

The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the

individual or entity named above. 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 information in error, please notify the sender

immediately and arrange for the return or destruction of the documents.

F14

04.17.2013