Pharmacy/Medication Prior Authorization Form

 
* = Required
Request Type*

 
PLEASE NOTE: Inappropriate EXPEDITED requests hinder the authorization process of vital medication services to Providers and Members. Inappropriate requests may be reduced to Standard by Health Choice.
 
Member Information
Member Name*  
Member ID*
DOB (MM/DD/YYYY)*
 
Provider Information
Requesting Provider Name*  
NPI*
PCP (if different)
Office Contact Person*
Direct Phone Number*   Ext.
Fax Number*
 
Medication Information
Diagnosis 1 (Include ICD-9)*  
Diagnosis 2 (Include ICD-9)  
Diagnosis 3 (Include ICD-9)
 
Name of Medication (and J-code if applicable)* 
Dosage*
Quantity/Amount*
Refills (<12)*
Sig/Instructions*
Allergies*

 
List Formulary Medications Tried/When*

List Formulary Medications Contraindicated/Reasons*