Please Wait...

Prior Authorization Form -Form Fill

Q1

Plan/Medical Group Name
Q2

Phone/Fax Number
Q3

First Name

Name
Q4

Last Name

Name
Q5

MI
Q6

Month

Birth Date
Q7

Day

Birth Date
Q8

Year

Birth Date
Q9

Gender
Q10

Phone Number
Q11

Street Address

Address
Q12

Street Address Line 2

Address
Q13

City

Address
Q14

State / Province

Address
Q15

Zip Code

Address
Q16

First Name

Authorized Representative (if applicable)
Q17

Last Name

Authorized Representative (if applicable)
Q18

Authorized Representative Phone Number
Q19

Primary Insurance Name
Q20

Patient ID Number
Q21

Secondary Insurance Name
Q22

First Name

Prescriber Name
Q23

Last Name

Prescriber Name
Q24

Speciality
Q25

First Name

Requestor (if different than prescriber)
Q26

Last Name

Requestor (if different than prescriber)
Q27

First Name

Office Contact Person
Q28

Last Name

Office Contact Person
Q29

NPI Number (individual)
Q30

DEA Number (if required)
Q31

Fax Number
Q32

Email Address
Q33

Medication Name
Q34

Type
Q35

How did the patient receive the medication?
Q36

Dose / Strength
Q37

Frequency
Q38

Length of Therapy / #Refills
Q39

Quantity
Q40

Administration
Q41

Administration Location
Q42

Has the patient tried any other medications for this condition?
Q43

ICD-9/ICD-10
Q44

Required Clinical Information
Q45

Prescriber Signature
Q46

Date of Decision
Q47

Status
Q48

Comments/Information Requested