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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).