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402-753-2800 | F: [888-810-1394 | savrx.com](888-810-1394 | savrx.com)  \n\n| NOTES TO PHYSICIAN: |\n| --- |\n|  |\n\n[Email Us At:](Email Us At: PriorAuth@SavRx.com)[ PriorAuth@SavRx.com](Email Us At: PriorAuth@SavRx.com)[ ](Email Us At: PriorAuth@SavRx.com)Date/Time: 09/26/2024 04:02:01 PM Agent: krezac  \n\n| Patient Information |  |  |\n| --- | --- | --- |\n| Name: JANE DOE | Card ID: 0014W00003HS5UGAAY | DoB: 01/01/1950 Sex:F |\n| Address: 224 NORTH PARK AVE FREMONT NE 68025 | Phone: . | Group: TESTUNION |\n| Doctor Information |  |  |\n| Dr. Name: | Phone: | Fax: |\n| Pharmacy Information |  |  |\n| Pharmacy Name: | Phone: | Fax: |\n| Drug Information |  |  |\n| Drug: Str: Qty: Directions: |  |  |\n| Drug Prior Authorization Review |  |  |\n| CLINICAL INFORMATION |  |  |\n| 1. Diagnosis:\u003Cbr>\u003Cbr>2. Rationale for use:\u003Cbr>\u003Cbr>3. Expected Duration of use:\u003Cbr>|  |  |\n| PERTINENT MEDICATION HISTORY |  |  |\n| 1. Drug:  Date:  Outcome:\u003Cbr>|  |  |\n\n[https://docster.savrx.com/docster2/tools/help](https://docster.savrx.com/docster2/tools/help) forms/ajax/action. php 1/2  \n9/26/24, 4:02 PM [docster.savrx.com/docster2/tools/help](docster.savrx.com/docster2/tools/help) forms/ajax/action. php  \n\n| 2. Drug: |  | Date: |  | Outcome: |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| 3. Drug: |  |  |  |  | |  |\n|  |  |  |  |  |  |  |\n|  |  | Date: |  | Outcome: |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| 4. Drug: |  |  |  |  | |  |\n|  |  |  |  |  |  |  |\n|  |  | Date: |  | Outcome: |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| 5. Drug: |  |  |  |  | |  |\n|  |  |  |  |  |  |  |\n|  |  | Date: |  | Outcome: |  |  |\n|  |  |  |  |  | |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n\n\n| Physician Signature | Date |\n| --- | --- |\n|  |  |\n\nTHE INFORMATION CONTAINED IN THIS FORM IS PROPRIETARY AND MAY CONTAIN PRIVILEGED OR CONFIDENTIAL INFORMATION. THE DISTRIBUTION, DISCLOSURE, VIEWING, COPYING, OR USE OF THIS INFORMATION, WITHOUT THE EXPRESS WRITTEN CONSENT OF SAV-RX PRESCRIPTION SERVICES, IS STRICTLY PROHIBITED.  \n[https://docster.savrx.com/docster2/tools/help](https://docster.savrx.com/docster2/tools/help) forms/ajax/action. php 2/2","cbCaid9VQKSBnc2s","https://ap.wps.com/l/cbCaid9VQKSBnc2s","pdf",113562,"English","# Patient Information\n# Doctor Information\n# Pharmacy Information\n# Drug Information\n# Drug Prior Authorization Review\n## Clinical Information\n## Pertinent Medication History\n# Physician Signature","[{\"question\":\"What sections does the form include for prior authorization review?\",\"answer\":\"It contains patient, doctor, pharmacy, and drug information sections, followed by a Drug Prior Authorization Review area covering clinical information and pertinent medication history.\"},{\"question\":\"Which clinical details must be provided?\",\"answer\":\"The form provides fields for diagnosis, rationale for use, and expected duration of use.\"},{\"question\":\"How is the physician’s decision or submission documented?\",\"answer\":\"The form includes a Physician Signature and a Date field for sign-off.\"}]","AA_Services_LLC | PDF",1789633365]