Transcription of PRESCRIPTION D PRIOR AUTHORIZATION …
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PRESCRIPTION D PRIOR AUTHORIZATION …
Page 1 of 2. PRESCRIPTION drug PRIOR AUTHORIZATION request form . Plan/Medical Group Name: Care1st Health Plan Plan/Medical Group Phone#: (877) 792-2731. Plan/Medical Group Fax#: (323) 889-6254 or (866) 712-2731. Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, chart notes or lab data, to support the PRIOR AUTHORIZATION request . Patient Information: This must be filled out completely to ensure HIPAA compliance First Name: Last Name: MI: Phone Number: Address: City: State: Zip Code: Date of Birth: Male Circle unit of measure Allergies: Female Height (in/cm): _____Weight (lb/kg):_____.
Page 1 of 2 New 08/13 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Plan/Medical Group Name: Care1st Health Plan Plan/Medical Group Phone#: (877) 792-2731 Plan/Medical Group Fax#: (323) 889-6254 or (866) 712-2731
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