Medication Prior Authorization Form

Your pharmacy may tell you that your insurance requires a Prior Authorization in order for them to cover costs on a medication. If this is the case, please fill out the following form for us so that we may initiate that process for you and fill out the appropriate paperwork. Please note that once we submit the request, the insurance company may take anywhere from 24 hours up to a week (and in some rare instances, longer) to return a determination to us. Once we hear back, we will inform you of the insurance’s decision.

In the meantime, you can use a coupon from GoodRX.com or from the prescription manufacturer’s website to find the best price for the prescription.

Sign in to Google to save your progress. Learn more
What is the patient's
First Name *
Last Name *
Address *
Phone Number *
DOB *
MM
/
DD
/
YYYY
Insurance information
Carrier name *
Member ID *
Plan Name *
BIN # *
PCN # *
RxGroup *
Medication information
Medication name *
Dose *
Instructions *
What medications have you tried before? *
How long were they tried? *
What was the reason for discontinuation? *
How long have you been on current medications? *
Back to https://www.pathgroupatl.com
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Path Group of Atlanta LLC.

Does this form look suspicious? Report

Google Forms