A fill-in prior authorization letter with patient, plan, medication, clinical-record and prescriber fields.
Date:
Patient name:
Date of birth:
Member ID:
Plan:
Requested medication:
Requested dose:
Prescriber:
To: ______________________________
Re: ______________________________
I am requesting review of the medication listed above for the patient identified here.
Diagnosis documented in record:
Relevant clinical criteria:
Previous treatments and dates:
Response to previous treatments:
Supporting records attached:
Requested treatment period:
Prescriber contact:
Prescriber signature: