MEDICATION PRE-AUTHORIZATION FORM
Please fill out all fields. If something does not apply, enter N/A.
Patient’s Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Current Insurance Information
Insurance Company
*
Member ID
*
Group Number
*
BIN/PCN
*
Upload front and back of insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Details
*
Preferred Pharmacy Information
Pharmacy Name
*
Phone Number
*
Please enter a valid phone number.
Address or location
*
Company that is requesting the preauthorization:
Name
*
Company Name
*
Phone Number
*
Please enter a valid phone number.
Fax Number
*
Medication details
Medication Name
*
Dosage & Strength
*
Quantity
*
Whether it’s new or a continuation
*
Clinical justification
(What insurers usually require)
Relevant symptoms
*
Previous medication trials (names, doses, duration, response, side effects) if applicable
*
N/A
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