Form F14 "Prior Authorization Form - General Request Form - Express Scripts"

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Download Form F14 "Prior Authorization Form - General Request Form - Express Scripts"

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Prior Authorization Form
General Request Form
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
Additional forms available:
www.express-scripts.com/pa
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Diagnosis: _________________________________________ ICD Code: ________________________________________
Please indicate which drug and strength is being requested:
________________________________________________________________
Quantity Requested
for
days supply
___________________________________________
_________________________________________________
Other Medications/Therapies tried and reason(s) for failure and/or any other information the physician feels is important to the review:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prescriber Signature: __________________________________________Date: ____________________
Office Contact Name: ___________________________ Phone Number: __________________________
Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any
questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.
Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a
treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information
regarding benefits, conditions, limitations, and exclusions.
The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the
individual or entity named above. 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 received this information in error, please notify the sender
immediately and arrange for the return or destruction of the documents.
F14
04.17.2013
Prior Authorization Form
General Request Form
This form is based on Express Scripts standard criteria and may not be
Fax completed form to 1-877-329-3760
applicable to all patients; certain plans and situations may require
additional information beyond what is specifically requested.
If this an URGENT request, please call 1-800-753-2851
Additional forms available:
www.express-scripts.com/pa
Patient Information
Prescriber Information
Patient First Name: ______________________________
Prescriber Name: _________________________________
Prescriber DEA/NPI (required): ______________________
Patient Last Name: _______________________________
Prescriber Phone #: _______________________________
Patient ID#: _____________________________________
Prescriber Fax #: _________________________________
Patient DOB: ____________________________________
Prescriber Address: _______________________________
Patient Phone #: _________________________________
State: ________________ Zip Code: __________________
Diagnosis: _________________________________________ ICD Code: ________________________________________
Please indicate which drug and strength is being requested:
________________________________________________________________
Quantity Requested
for
days supply
___________________________________________
_________________________________________________
Other Medications/Therapies tried and reason(s) for failure and/or any other information the physician feels is important to the review:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prescriber Signature: __________________________________________Date: ____________________
Office Contact Name: ___________________________ Phone Number: __________________________
Based upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any
questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.
Prior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a
treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information
regarding benefits, conditions, limitations, and exclusions.
The document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the
individual or entity named above. 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 received this information in error, please notify the sender
immediately and arrange for the return or destruction of the documents.
F14
04.17.2013