Prior Authorization
Request Date :
05-02-2024
Authorization Request For
Self
Spouse
Dependent
Patient Information
First Name
Last Name
Gender
Female
Male
Unspecified
Height
Weight
Date of Birth
Allergies
Cardholder Name
Cardholder Employer
Prescription Id # on Card
Prescription Group # on Card
Patient (or Caregiver) Phone
Cell Phone
Address
Address 2 (optional)
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Email
Prescriber Information
Prescriber Name
NPI
Office Contact Person
Prescriber Specialty
Address
Medical Facility Name
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Prescriber Phone
Fax
Medication Information
Medication Requested
Strength
Quantity
Instructions for Use
Day Supply
ICD Code and/or Diagnosis
Expected Length of Therapy
Date Needed
Tried/Failed Therapies for this Request
Previous Medication
Strength
Sig
Duration (start/end date)
Results
Previous Medication
Strength
Sig
Duration (start/end date)
Results
Previous Medication
Strength
Sig
Duration (start/end date)
Results
PA Time Frame
One Year
Six Months
Other (Specify Time Frame for Treatment)
PA Time Frame (Other)
Attachments
Submit
