Diversity Family Health Injectable Pre-Authorization Form

Pre-Authorization Form for Injectable Prevention or Treatment
Medication*

Apretude for PrEPCabenuva for Treatment
Billing Name*

PrefixFirst NameLast Name
Social Security Number
Date of Birth*

MonthDayYear
Date
Billing Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Insurance Information

Insurance is required to obtain Apretude and Cabenuva. If you have insurance please complete the form. If you want to apply for insurance go to www.healthcare.gov or your state medicaid site. Medicaid commonly pays for Apretude and Cabenuva.
Insurance

CommercialMedicareMedicaid/SoonercareOther
Insurance Company
ID/Policy #
Group #
Copay/Co Insurance Amount
Effective Date

MonthDayYear
Date
Race*
Once you submit the pre-authorization form one of our billing specialists will check with your insurance company about coverage and then contact you with the outcome and if approved book your consultation appointment to start injectable prevention or treatment. We look forward to providing you with great care!
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Pre-Authorization Form for Injectable Prevention or Treatment