PRIOR AUTHORIZATION REQUEST FORM

PRIOR AUTHORIZATION REQUEST FORM
** THIS IS NOT A REFILL REQUEST **

*** IMMEDIATE ATTENTION IS REQUIRED*
The patient identified below requires prior authorization for the prescription indicated. Pleasereview the information below and contact the insurance company at the number provided. If youhave any questions concerning this request, please contact us by calling (215) 861-7007
PRESCRIBER INFORMATION
Prescriber Name*

First NameLast Name
Prescriber Email
example@example.com
Prescriber Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescriber NPI*
Prescriber Phone Number*
Please enter a valid phone number.
Prescriber Fax
Please enter a valid phone number.
PATIENT INFORMATION
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Facility Name
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Fax
Please enter a valid phone number.
INSURANCE INFORMATION
Plan Information*
Patient ID*
Prior Auth Phone
Please enter a valid phone number.
MEDICATION/PRODUCT AND DISPENSING INFORMATION

Medication Name, Strength form:
RX #
Date Written

MonthDayYear
Date
Directions
QTY
Date of Fill

MonthDayYear
Date
Comments
Signature*

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Date*

MonthDayYear
Date
Internal use ONLY

You don't need to fill this out!
Response from Insurance

ApprovedDenied
Date from, if approved

MonthDayYear
Date
Date to, if approved

MonthDayYear
Date
Information
Should be Empty:

** THIS IS NOT A REFILL REQUEST **