Medication Prior Authorization Form
Hi!

We have received information from your pharmacy that your insurance is not covering your medication.


Can you please help us with the following questions to be able to submit the pre-authorization promptly and accurately. Please keep in mind that authorizations can be a lengthy process and generally take at least 72 hours to complete.

What is the patient's
First Name
Your answer
Last Name
Your answer
Address
Your answer
DOB
MM
/
DD
/
YYYY
Insurance information
Carrier name
Your answer
Member ID
Your answer
Plan Name
Your answer
BIN #
Your answer
PCN #
Your answer
RxGroup
Your answer
Medication information
Medication name
Your answer
Dose
Your answer
Instructions
Your answer
What medications have you tried before?
Your answer
How long were they tried?
Your answer
What was the reason for discontinuation?
Your answer
How long have you been on current medications?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Path Group of Atlanta LLC. Report Abuse - Terms of Service - Additional Terms