Form F-00080 - Prior Authorization / Preferred Drug List (Pa/pdl) For Symlin Page 2

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PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR SYMLIN
Page 2 of 2
F-00080 (10/11)
SECTION VI — FOR PHARMACY PROVIDERS USING STAT-PA
23. National Drug Code (11 Digits)
24. Days’ Supply Requested (Up to 365 Days)
25. NPI
26. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14
days in the past.)
27. Place of Service
28. Assigned PA Number
29. Grant Date
30. Expiration Date
31. Number of Days Approved
SECTION V — AUTHORIZED SIGNATURE
32. SIGNATURE — Prescriber
33. Date Signed
SECTION VI — ADDITIONAL INFORMATION
34. 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.
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