Prior Authorization For Stimulants And Related Drugs Page 2

Download a blank fillable Prior Authorization For Stimulants And Related Drugs in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Prior Authorization For Stimulants And Related Drugs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR STIMULANTS AND RELATED AGENTS
Page 2 of 2
F-11097 (12/12)
SECTION IIIB — CLINICAL INFORMATION FOR KAPVAY REQUESTS ONLY
14. Will the member take Kapvay in combination with a preferred stimulant?
Yes
No
If yes, list the preferred stimulant in the space provided.
15. Has the member experienced an unsatisfactory therapeutic response or experienced a clinically
significant adverse drug reaction with a preferred stimulant?
Yes
No
If yes, list the preferred stimulant and dose, specific details about the unsatisfactory therapeutic response or clinically significant
adverse drug reaction, and the approximate dates the preferred stimulant was taken in the space provided.
16. Does the member have a medical condition(s) preventing the use of a preferred stimulant?
Yes
No
If yes, list the medical condition(s) that prevents the use of a preferred stimulant in the space provided.
17. Is there a clinically significant drug interaction between another medication the member
is taking and a preferred stimulant?
Yes
No
If yes, list the medication(s) and interaction(s) in the space provided.
SECTION IV — AUTHORIZED SIGNATURE
18. SIGNATURE — Prescriber
19. Date Signed
SECTION V — FOR PHARMACY PROVIDERS USING STAT-PA
20. National Drug Code (11 Digits)
21. Days’ Supply Requested (Up to 365 Days)
22. NPI
23. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future or up to 14 days
in the past.)
24. Place of Service
25. Assigned PA Number
26. Grant Date
27. Expiration Date
28. Number of Days Approved
SECTION VI — ADDITIONAL INFORMATION
29. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the
drug requested may also be included here.
Reset Form

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Prior Authorization For Cytokine And Cell Adhesion Molecule Antagonist Drugs For Rheumatoid Arthritis And Polyarticular Juvenile Ra Form Prior Authorization For Cytokine And Cell Adhesion Molecule Antagonist Drugs For Rheumatoid Arthritis And Polyarticular Juvenile Ra Form Legal
Stimulants And Related Agents Prior Authorization Form Stimulants And Related Agents Prior Authorization Form Medical
Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Business
Prior Authorization / Hearing Instrument And Audiological Services Prior Authorization / Hearing Instrument And Audiological Services Medical
Prior Authorization For Psychotherapy Prior Authorization For Psychotherapy Legal
Prior-authorization For Payment Of Orfadin Template - Prescriber's Statement Of Medical Necessity Prior-authorization For Payment Of Orfadin Template - Prescriber's Statement Of Medical Necessity Medical
Authorization For Release And Disclosure, And/or Request For Medical Information And Records Authorization For Release And Disclosure, And/or Request For Medical Information And Records Legal
Authorization For Disclosure And Release Of Medical Information Form Authorization For Disclosure And Release Of Medical Information Form Legal
Authorization For Use And Disclosure Of Protected Health Information Form Authorization For Use And Disclosure Of Protected Health Information Form Legal
Authorization For Cremation And Disposition Form Authorization For Cremation And Disposition Form Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2