Phone: 800-555-2546 Fax back to: 1-877-486-2621. Humana manages the pharmacy drug benefit for your patient. Certain requ
Plan name: ... Verify with the preauthorization list on the One Health Port, according to the company's procedure, or ca
PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM. Plan/
Medical Group Name: Care1st Health Plan. Plan/Medical Group Phone#: (877)
792- ...
Care1st Internal Use re sr. HEALTH PLAN DOE;. Medication Prior Authorization
Form IPA: LOB: Pharmacy Department Fax: (323) 889-6254 or (866) 712-2 731.
TennCare Pharmacy Program, c/o Magellan Health Services, 1st Floor South, ... If
the following information is not complete, correct, or legible, the PA process ...
Call Center ID: _____ Tax ID Number: Plan ID: ___ Benefit: Office Fax Number: Phone Number: Office Address: MEMBER INFOR
If you have received this electronic fax transmission in error, please notify the sender immediately and return the docu
Project Index Number (or Coeus # if no index yet). (Name and Department). Sponsor: ... Include detailed information on f
Attach additional pages, if necessary. 3. REQUIRED APPROVAL SIGNATURES. Principal Investigator. DATE. *Director/Chair or
Access this PA form at ... TennCare Pharmacy Program, c/o Magellan Health
Services, 1st Floor South, 14100 Magellan ... Treatment of active opiate addiction
.
Please Note: Medical Necessity Prior Authorization may be utilized to ... First
Name ... Dialysis:______ Long Term Care Facility:______ Self Injecting:______.
2013-14 Computer-based GRE® revised General Test. Authorization Voucher
Request Form. Use this form ONLY if you are paying with a fee reduction ...
Return Merchandise Authorization (RMA) Request Form. Please fill out this form
completely. Pantone Customer Service will contact you to provide the RMA.
Fax to: (877) 431-8860 ... Required Information: In order to ensure our members receive quality care, appropriate claims
Fax to: (877) 431-8860. CHECK ... Required Information: In order to ensure our members receive quality care, appropriate
for the purpose of picking up my Test Report Form for the test taken on ... A letter
of authorization to include: authorize full name, candidate number, test date & ...
Reason for Request: Prior. Treatment. &. Results: Relevant labs/X-Rays, etc: □
Health ... DENIAL. AUTH #:_. Date Approved: Date Auth. Expire: Comments:
Reviewer's Name: Signature:_. Date: CARE 1st USE ONLY: Member Eligibility as
of:.
Jan 15, 2014 ... “exclusive” contractors listed in the Exhibitor Services Manual, hired to provide a
... the 2014 IADC/SPE Drilling Conference and Exhibition.
May 1, 2014 - For assistance please contact Utilization Management a 1-855-371-8074. Providers are responsible to obtain
Department of Mental Health. Patton State Hospital. PSH 7383, Revised 7/10.
VISITORS' REQUEST AND AUTHORIZATION FORM. PLEASE READ ...
Contractor shall not require prior authorization or a referral as a condition of payment for school health center servic
Please complete and fax this form to Caremark at 888-836-0730 to request a
Drug Specific Prior ... fax the Drug Specific Prior Authorization Request Form to
us, we will review it and notify you and ... Last Name, First Name (PLEASE PRINT
).
CAREMARK PRIOR AUTHORIZATION FORM REQUEST Please complete and fax this form to Caremark at 888-836-0730 to request a Drug Specific Prior Authorization Form. Once we receive your request, we will fax you a Drug Specific Prior Authorization Request Form along with the patient’s specific information and questions that must be answered. When you fax the Drug Specific Prior Authorization Request Form to us, we will review it and notify you and the patient of the result. If we deny your request, we will also provide you and the patient with the denial reason.
SECTION I: PATIENT INFORMATION Last Name, First Name (PLEASE PRINT)
Date of Birth (MM/DD/YYYY)
Street Address
Phone Number ( )
City
State
Cardholder ID #
ZIP Code
SECTION II: DRUG INFORMATION Drug Name (PLEASE PRINT)
Drug Strength
SECTION III: PRESCRIBER INFORMATION Prescriber’s Name (PLEASE PRINT) Prescriber’s Address (Street, City, State, ZIP code) Prescriber’s Phone Number ( )
Prescriber’s Fax Number ( )
Incomplete or illegible forms and missing fields will delay the processing of your request. Please complete all fields to ensure appropriate processing. CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments.
PRIVACY DISCLAIMER: Patient privacy is important to us. Our employees are trained regarding the appropriate way to handle private health information.
