To ensure a timely, response, please fill out the form completely and legibly and include required clinical documentation. MEMBER INFORMATION Name (Last, First): Member ID #: DOB: Date: Address: City: State: Zip: Preferred Language: Gender: Male Phone: Height: Weight: Female Guardian’s Name: Phone: Address: City: State: Zip: PRESCRIBER INFORMATION Name (Last, First): Practice Name: Specialty: NPI: Address: City: State: Zip: Office Contact Person: Direct Phone #: Fax #: PRESCRIPTION INFORMATION (Please send all pertinent clinical documentation with this fax). Use of pharmaceutical samples cannot be accepted as justification. ICD 10: Diagnosis: Date of Diagnosis: Allergies: Name of Medication: Dosage: Quantity/Amount: Length of Therapy: Signature/Instructions: Pharmacy Name: Phone Number: Fax Number: List Formulary Medication Tried (include length of treatment and response with dates): This is a reauthorization of current medication. Recent clinical documentation is required. Please provide. Prescriber Signature: Date of Request: CONFIDENTIALITY NOTICE: This fax transmission, including any attachments, contains confidential information that may be privileged. The information is intended only for the use of the individual(s) or entity to which it is addressed. If you are not the intended recipient, any disclosure, distribution or the taking of any action in reliance upon this fax transmission is prohibited and may be unlawful. If you have received this fax in error, please notify the sender immediately via telephone at 866-495-6738 and destroy the original documents. Thank you.
To ensure a timely, response, please fill out the form completely and legibly and include required clinical documentation. MEMBER INFORMATION Name (Last, First): Member ID #: DOB: Date: Address: City: State: Zip: Preferred Language: Gender: Male Female Phone: Height: Weight: Guardian’s Name: Phone: Address: City: State: Zip: PRESCRIBER INFORMATION Name (Last, First): Practice Name: Specialty: NPI: Address: City: State: Zip: Office Contact Person: Direct Phone #: Fax #: PRESCRIPTION INFORMATION (Please send all pertinent clinical documentation with this fax). Use of pharmaceutical samples cannot be accepted as justification. ICD 10: Diagnosis: Date of Diagnosis: Allergies: Name of Medication: Dosage: Quantity/Amount: Length of Therapy: Signature/Instructions: Pharmacy Name: Phone Number: Fax Number: List Formulary Medication Tried (include length of treatment and response with dates): This is a reauthorization of current medication. Recent clinical documentation is required. Please provide. Prescriber Signature: Date of Request: CONFIDENTIALITY NOTICE: This fax transmission, including any attachments, contains confidential information that may be privileged. The information is intended only for the use of the individual(s) or entity to which it is addressed. If you are not the intended recipient, any disclosure, distribution or the taking of any action in reliance upon this fax transmission is prohibited and may be unlawful. If you have received this fax in error, please notify the sender immediately via telephone at 866-495-6738 and destroy the original documents. Thank you.
PMF_10-11-2%20-%20Rev%2012-18-17.docx