"Prior Authorization Request Form - Cvs Caremark"

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PRIOR AUTHORIZATION REQUEST FORM
**Please note that this form is to be completed by the prescribing physician. This form and its contents are permissible under HIPAA,
as the protected health information (PHI) contained in this letter is only being used for purposes related to the provision of treatment,
payment, and healthcare operations (TPO). HIPAA does not restrict the communication of PHI with providers for TPO related
purposes.
Date of Request________________
Case #_________________
Member Name
DOB
Member Identification Number
TPC
Physician Name
DEA# / Specialty
Physician Phone #
Physician Fax #
Medication / Dose Requested:
We have received your request for prior authorization for the patient and medication listed above. In
order to complete our review and make an appropriate determination, the following information will be
necessary:
Diagnosis: _____________________________________
ICD-9 Code: _________________
Previous medication treatment history:
_____________________________________________________________________________________________
Other relevant patient information:
____________________________________________________________
______________________________________________________________________________________________
Physician Signature: __________________________________________Date:____________
**Physician signature field must be completed. Requests will not be reviewed in the event that this field is incomplete.
**Please call 1-800-952-9684 for assistance in filling out this form. (Dr. office only). Most requests are processed within one business day
of receiving complete information. Some requests may, however, require more time to review.
COMPLETED FORMS MAY BE FAXED TO 1-800-230-0783
PRIOR AUTHORIZATION REQUEST FORM
**Please note that this form is to be completed by the prescribing physician. This form and its contents are permissible under HIPAA,
as the protected health information (PHI) contained in this letter is only being used for purposes related to the provision of treatment,
payment, and healthcare operations (TPO). HIPAA does not restrict the communication of PHI with providers for TPO related
purposes.
Date of Request________________
Case #_________________
Member Name
DOB
Member Identification Number
TPC
Physician Name
DEA# / Specialty
Physician Phone #
Physician Fax #
Medication / Dose Requested:
We have received your request for prior authorization for the patient and medication listed above. In
order to complete our review and make an appropriate determination, the following information will be
necessary:
Diagnosis: _____________________________________
ICD-9 Code: _________________
Previous medication treatment history:
_____________________________________________________________________________________________
Other relevant patient information:
____________________________________________________________
______________________________________________________________________________________________
Physician Signature: __________________________________________Date:____________
**Physician signature field must be completed. Requests will not be reviewed in the event that this field is incomplete.
**Please call 1-800-952-9684 for assistance in filling out this form. (Dr. office only). Most requests are processed within one business day
of receiving complete information. Some requests may, however, require more time to review.
COMPLETED FORMS MAY BE FAXED TO 1-800-230-0783