"Prior Authorization Form Request - Cvs Caremark"

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CAREMARK
PRIOR AUTHORIZATION FORM REQUEST
Please complete and fax this form to Caremark at 888-836-0730 to request a Drug Specific Prior
Authorization Form. Once we receive your request, we will fax you a Drug Specific Prior Authorization
Request Form along with the patient’s specific information and questions that must be answered. When you
fax the Drug Specific Prior Authorization Request Form to us, we will review it and notify you and the patient
of the result. If we deny your request, we will also provide you and the patient with the denial reason.
SECTION I: PATIENT INFORMATION
Last Name, First Name (PLEASE PRINT)
Date of Birth (MM/DD/YYYY)
Street Address
Phone Number
(
)
City
State
Cardholder ID #
ZIP Code
SECTION II: DRUG INFORMATION
Drug Name (PLEASE PRINT)
Drug Strength
SECTION III: PRESCRIBER INFORMATION
Prescriber’s Name (PLEASE PRINT)
Prescriber’s Address (Street, City, State, ZIP code)
Prescriber’s Phone Number
Prescriber’s Fax Number
(
)
(
)
Incomplete or illegible forms and missing fields will delay the processing of your request. Please complete all
fields to ensure appropriate processing.
CONFIDENTIALITY NOTICE:
This communication and any attachments may contain confidential and/or privileged information for the use
of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in
error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in
error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments.
PRIVACY DISCLAIMER:
Patient privacy is important to us. Our employees are trained regarding the appropriate way to handle private
health information.
CAREMARK
PRIOR AUTHORIZATION FORM REQUEST
Please complete and fax this form to Caremark at 888-836-0730 to request a Drug Specific Prior
Authorization Form. Once we receive your request, we will fax you a Drug Specific Prior Authorization
Request Form along with the patient’s specific information and questions that must be answered. When you
fax the Drug Specific Prior Authorization Request Form to us, we will review it and notify you and the patient
of the result. If we deny your request, we will also provide you and the patient with the denial reason.
SECTION I: PATIENT INFORMATION
Last Name, First Name (PLEASE PRINT)
Date of Birth (MM/DD/YYYY)
Street Address
Phone Number
(
)
City
State
Cardholder ID #
ZIP Code
SECTION II: DRUG INFORMATION
Drug Name (PLEASE PRINT)
Drug Strength
SECTION III: PRESCRIBER INFORMATION
Prescriber’s Name (PLEASE PRINT)
Prescriber’s Address (Street, City, State, ZIP code)
Prescriber’s Phone Number
Prescriber’s Fax Number
(
)
(
)
Incomplete or illegible forms and missing fields will delay the processing of your request. Please complete all
fields to ensure appropriate processing.
CONFIDENTIALITY NOTICE:
This communication and any attachments may contain confidential and/or privileged information for the use
of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in
error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in
error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments.
PRIVACY DISCLAIMER:
Patient privacy is important to us. Our employees are trained regarding the appropriate way to handle private
health information.