DisclosedRx | Prior Authorization

Prior Authorization

Request Date : 07-05-2025

Patient Information:

Patient Name

Gender

Date of Birth

Cardholder ID

Street Address

City

State

Zip

Prescriber Information:

Prescriber Name

Prescriber Specialty

NPI

Office Contact Person

Street Address

City

State

Zip

Prescriber Phone

Prescriber Fax

Medication Information:

Drug Name

Strength

Directions

Quantity

Day Supply

ICD 10 Code

Diagnosis

Expected Length of Therapy

Prior Authorization Questions:

1. Does the patient have any FDA contraindications to the requested agent? Yes No

2. Will the patient be taking any other medications in combination with the requested agent for the treatment of this diagnosis? If yes, please list: Yes No

3. Has the patient had an inadequate clinical response of at least 12 weeks, intolerance, or contraindication to any medications used to treat this diagnosis? Yes No

If yes, please list:

Medication 1 Name/Strength

Medication 1 Start/End Date

Medication 1 Outcome

Medication 2 Name/Strength

Medication 2 Start/End Date

Medication 2 Outcome

Medication 3 Name/Strength

Medication 3 Start/End Date

Medication 3 Outcome

Attachments