Transcription of Medication Prior Authorization Form - Better Health
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Medication Prior Authorization Form - Better Health
Medication Prior Authorization form Fax back to: 305-402-5800 Phone: 1-877-577-9044. Email: Member Information Last Name: First Name: : ID Number: Prescriber Information Name: NPI: Specialty: Phone Number: Fax Number: Medication Requested: (Please include name, strength, quantity and directions): Estimated duration of therapy: Diagnosis and pertinent clinical information: Previous medications tried for this diagnosis and when: Outcome of previous treatment and/or reason for intolerance to the formulary Medication : Duration of treatment with previous Medication : IF THIS IS A REQUEST FOR REAUTHORIZATION of a previously approved requested, please provide recent clinical documentation.
D.O.B.: Name: Duration at AM Specialty: Medication Prior Authorization Form Fax back to: 305-402-5800 Phone: 1-877-577-9044 Member Information
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