Transcription of Medicare Part B Medication PRIOR AUTHORIZATION …
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Medicare Part B Medication PRIOR AUTHORIZATION …
Medicare part B Medication PRIOR AUTHORIZATION . request form Patient's Name: Date of Birth: ID #: Group #: Prescribing Doctor: Phone #: Pharmacy provider (If applicable): Phone #: Requested Medication : Name: Strength: Directions: Start Date: End Date: # of Doses Requested: Requested Medication : Name: Strength: Directions: Start Date: End Date: # of Doses Requested: Treatment Diagnosis: Other medications previously tried: Additional information supporting request (attach chart notes and/or labs if applicable): Comments: Sent by: Phone #: Please fax this form to 1-855-874-4711, Attention: UM Intake For questions, call Customer Service at 1-877-774-8592. Blue Cross and Blue Shield of Texas refers to hcsc Insurance Services Company (HISC), which is a wholly-owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company ( hcsc ).
Medicare Part B Medication PRIOR AUTHORIZATION Request Form Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company (HISC), which is a
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