Medication Request Form

Patient Information

** Please include a copy of the front & back of all insurance cards**

Name:

Date Of Birth:

Gender:

Allergies:

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone:

Insurance Plan:

Insurance Id:

Patient Weight:

Rx Group:

Rx Bin:

Rx PCN:

Prescription Selection:

Medications:

Directions:

Quantity:

Refills:

New Therapy

Continuing Therapy

Diagnosis/ICD-10:

New Therapy

Continuing Therapy

Diagnosis/ICD-10:

New Therapy

Continuing Therapy

Diagnosis/ICD-10:

New Therapy

Continuing Therapy

Diagnosis/ICD-10:

Clinical Information:

Please submit the most recent Prescriber Notes, Lab/test results, and Prescriptions

Please attach or describe any other information related to this request:

Medication(s) Failed:

Discontinuation Reason

Therapy Duration

Prescriber Information:

Name:

Specialty:

DEA:

NPI:

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone:

Fax:

Office Contact:

Ext:

I certify

that the above information is true and accurate to the best of my knowledge. I authorize Pharmacy Advantage Specialty Pharmacy and its representatives to act as an agent to initiate and complete insurance prior authorizations.

Prescriber Signature:

Date:

Requester Signature:

Date:

This field is for validation purposes and should be left unchanged.