Download Microsoft InfoPath - (Preview) Guam PA

LDI Integrated Pharmacy Services
701 Emerson Road, Suite 301
Creve Coeur, MO 63141
Phone (314)652­3121 Fax (877)504­4551
Prior Authorization Form
Date:__________________
Complete the information below, sign and date. Please FAX completed forms to LDI at (877)504-4551. If the Plan's coverage conditions are met, coverage will be
authorized. Any questions please contact LDI at (866)-516-3121
Patient Information
Last Name:
First Name:
DOB:
Sex:
Prescriber Information
Prescriber Name:
Phone:
DEA/NPI:
Fax:
Prescriber Specialty:
Medication:________________________________________________
Dosage
Qty:
Directions:
Diagnosis:
Is the patient a new start?
Yes
No If no, how long has the patient been on the current therapy?
Proposed length of treatment:
Please list other medications the patient has tried to treat this condition:
Please submit relevant chart notes and labs showing clinical need
for medication requested or evidence of continued efficacy.
Comments:
Information given on this form is accurate as of this date.
_____________________________________________
Prescriber or Authorized Signature
___________________
Date
I understand that LDI Integrated Pharmacy Services use or disclosure of individually identifiable health information, whether furnished by me or obtained by another source such as
medical providers, shall be in accordance with federal regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996).