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PRESCRIPTION D PRIOR AUTHORIZATION REQUEST FORM

Page1of2 New 08/13 form 61 211 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST form Plan/Medical Group Name: Inland Empire Health Plan Plan/Medical Group Phone# :( 888) 860-1297 Plan/Medical Group Fax# :( 909) 890-2058 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 .

Page2of2 New 08/13 Form 61‐211 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Patient Name: ID#: Instructions: Please fill out all applicable sections on both pages completely and legibly.Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request.

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