Prior Authorization Web Form

Select Form

Request Information

Check if Urgent Note: The prescriber attests that applying the standard turnaround time could seriously jeopardize the life, health, or safety of the member or others, due to the member’s psychological state, or in the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.

Request Type

Initial

Appeal

Patient Information

First Name

Last Name

Middle Name (optional)

Phone Number (optional)

Address (optional)

City

State

ZIP Code (optional) Format: 5 digits

Date of Birth Format: mm/dd/yyyy

Gender

Height (optional)

Weight (optional)

Allergies (optional)

Appointed Rep. (AOR) (optional)

AOR Phone Number (optional)

Insurance Information

Primary Insurance Name

Primary Insurance ID Number

Secondary Insurance Name (optional)

Secondary Insurance ID Number (optional)

Prescriber Information

NPI Number (individual)

First Name

Last Name

Specialty

Address

City

State

ZIP Code

Phone Number

Fax Number (in HIPAA-compliant area)

Email Address (optional)

DEA Number (if required)

Office Contact Person (optional)

Requestor (if not the prescriber)

Medication/Medical and Dispensing Information

Medication to Search For Partial matches are allowed, starting with the beginning of the medication's name. (minimum of 3 characters required)

Quantity

Days Supply

Frequency

Total Number of Fills

Pharmacy Name (optional)

Pharmacy Phone Number (optional)

Pharmacy Fax Number (optional)

New Therapy

Renewal

Dispense As Written Note: If not checked, the request will be reviewed as "Generic Substitution Permitted"

Date Therapy Initiated (if renewal) Date format: mm/dd/yyyy

Duration of Therapy (specific dates)

Administration

Oral/SL

Topical

Injection

Other

Administration Location

Physician's Office

Ambulatory Infusion Center

Patient's Home

Home Care Agency

Outpatient Hospital Care

Long Term Care

Other

Has the patient tried any other medications for this condition?

Yes

If Yes, complete the three fields below.

Medication/Therapy (Drug Name and Dosage)

Duration of Therapy (Specify Dates)

Reason for Failure/Response/Allergy

Diagnoses

List of Diagnoses

ICD-10 Codes (if available)

Clinical Information Please provide all relevant clinical information to support a prior authorization review.

Clinical Explanation

List of Current Medications

Additional documentation included in attachments

Additional Attachments PDF files only. Maximum of 50 pages per attachment. Larger documents should be faxed to (833) 231-3647.

Please attach all relevant clinical information to support a prior authorization review. Helpful information to include:

Chart notes
Symptoms
Lab results with dates to establish diagnosis or evaluate response
Justification for initial or ongoing therapy or increased dose
If patient has any contraindications for the health plan/insurer preferred drug(s)
Any additional clinical information or comments pertinent to this request for coverage (e.g., formulary tier exceptions) or required under state and federal laws.

Attestation

I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, Insurer, Medical Group, or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.

Signature (enter name)

Signature Date Format: mm/dd/yyyy

Confidentiality Notice: The documents accompanying this submission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please arrange for the return or destruction of these documents immediately.