Drug Prior Authorization Form - Privacy consent, authorization, and declaration

Sep 17, 2026

Drug Prior Authorization Form collects the information needed to assess a drug claim and stresses that all questions must be answered to avoid delays. The form includes detailed privacy notice language covering what personal information is collected, how it is used to administer products, assess eligibility, process claims and financial transactions, and share data with supporting organizations. It also includes consent, authorization, and declaration statements, patient/plan member certification, audit rights, consent revocation options, and instructions for completing patient and physician sections.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

Privacy

How personal information is used

Who we share personal information with

Privacy consent, authorization, and declaration

Form completion instructions

Drug Prior Authorization Form The purpose of this form is to obtain information required to assess your drug claim. IMPORTANT: Please answer all questions. Your claim assessment will be delayed if this form is incomplete or contains errors. Any costs incurred for the completion of this form are the responsibility of the plan member/patient. Privacy Protecting your personal information. At Canada Life, we’re committed to protecting personal information and respecting your privacy. Personal information is information that either on its own or combined with other information allows an individual to be identified. This includes your name and address, as well as more sensitive information such as your health and financial records. When applicable, this includes information about other people such as your spouse, common-law partner, and children. How we use your personal information. Your personal information is used to provide you with products and services and to improve our business operations. This includes verifying your identity, maintaining your profile, and informing you about features of the products you already have with us. It’s also used to provide you with advice, evaluate your eligibility for products, price our products, collect feedback on our customer service, process claims and other financial transactions, protect you and us from risks such as cyber threats and fraud, and comply with legal obligations. If you provided your social insurance number (SIN), we’ll use it for tax reporting. Your SIN is also used to link your products together and to keep your information separate from other customers with similar names. Who we share personal information with. We share your personal information with other people and organizations who help us administer your products and provide you with services. This may include your advisor or people who work with your advisor, our Canadian subsidiaries, and other organizations that provide us services such as paramedical examiners, medical laboratories, MIB, LLC., specialty coverage providers, independent medical examiners, and pharmacy benefits managers. As well, we may share your information with claims assessors, travel assistance providers, technology suppliers, other insurance or reinsurance companies, other financial institutions, and credit reporting agencies. As part of our day-to-day business, your personal information may be communicated to government departments and agencies, and may be communicated outside your province of residence or outside Canada. We take protecting your personal information seriously and we’ll never sell your personal information to anyone. You’re in control of your personal information. We respect your privacy preferences and follow them when using your personal information. At any point in your relationship with us, you can choose how your personal information is used by updating your privacy preferences through your online account or by submitting a request [through our](through our privacy centre at canadalife.com/privacy. This)[ ](through our privacy centre at canadalife.com/privacy. This)[privacy centre](through our privacy centre at canadalife.com/privacy. This)[ at](through our privacy centre at canadalife.com/privacy. This)[ ](through our privacy centre at canadalife.com/privacy. This)[canadalife.com/privacy](through our privacy centre at canadalife.com/privacy. This)[. This](through our privacy centre at canadalife.com/privacy. This) includes choosing whether you receive customer experience surveys, the use of your SIN for non-tax reporting purposes, and whether and how you want to receive information and offers from Canada Life using the personal information we collect from you throughout your relationship with us. You can also exercise other privacy rights through our privacy centre such as access to or correction of your personal information. If you choose to remove your consent to the collection, use and disclosure of the

FAQs

What is the purpose of the Drug Prior Authorization Form?

It collects required information to assess the drug claim. Completing all questions is necessary to prevent assessment delays.

How does Canada Life use and process personal information on this form?

Personal information is used to provide products and services, improve operations, verify identity, evaluate eligibility, process claims and transactions, and meet legal obligations.

Can consent be revoked, and what happens if consent is removed?

Consent may be revoked by providing written instruction. If consent is removed for collection, use, or disclosure needed to serve you or meet legal obligations, Canada Life may not be able to continue providing products and services.

Sep 17, 2026

Uploaded by Lucas Martin