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Includes a confidentiality notice and sections for patient and prescriber information, medication details, therapy strength and dosing, and required clinical answers regarding indications, provider administration, specialist consultation, hepatic or renal dysfunction, and new versus existing therapy. 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The submission of this form does not guarantee approval and coverage of the medication requested. Documentation is required.\u003Cbr>Confidentiality Notice: This document contains confidential protected health information and intended for the recipient below. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the destruction of these documents. |  |  |  |  |  |  |  |  |\n|  |  | Patient Information |  |  | Prescriber Information |  |  |  |\n|  |  | Patient Name: | Patient ID: |  | Prescriber Name: | Specialty: |  |  |\n|  |  | Patient DOB: | Client ID: |  | Phone: | Fax: |  |  |\n|  |  | Date: | Request ID: |  | NPI: | DEA: |  |  |\n|  |  |  |  |  | Office Address: |  |  |  |\n|  |  | Prescriber use only: |  |  |  |  |  |  |\n| Strength: Quantity: Days Supply: Expected Duration of Therapy: Wt:  KG / LB (circle)\u003Cbr>Ht:  CM / IN (circle) Directions for use: Diagnosis: List Diagnosis Codes:\u003Cbr>Answer Section Below for All Requests:\u003Cbr>Is the requested medication being used for and FDA approved indication and dose/quantity? □ YES □ NO\u003Cbr>If NO, provide rationale and clinical literature supporting use:   Is the medication being administered by or under the guidance of a healthcare PROVIDER and/or in a physician’s office? □ PROVIDER □ PATIENT\u003Cbr>Is the medication being prescribed by, or in consultation with a specialist? □ YES □ NO\u003Cbr>Does the patient have hepatic or renal disfunction? □ YES □ NO\u003Cbr>If YES, specify:   Is the requested medication a NEW or EXISTING therapy? □ NEW □ EXISTING\u003Cbr>If EXISTING therapy, how long has the patient been on the requested medication?  Please list ALL medications the patient has tried for this diagnosis and specify reason.\u003Cbr>Medication and strength Reason for failure / Contraindication Trial date\u003Cbr>_____________________________ ___________________________________ _____________________\u003Cbr>_____________________________ ___________________________________ _____________________\u003Cbr>_____________________________ ___________________________________ _____________________\u003Cbr>**All requests require documentation. Please submit chart notes and relevant clinical information including lab values** |  |  |  |  |  |  |  |  |\n|  | CURRENT THERAPY: Medication(s) dose(s), duration(s) and date(s) |  |  | TRIALED THERAPY: Medication(s) dose(s), duration(s) and date(s) |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  | Additional Relevant Clinical Information: |  |  |  |  |  |  |  |\n| \u003Cbr>Attestation: I attest the information and supporting documentation provided is accurate, complete, and true to the best of my knowledge.\u003Cbr>Prescriber Signature:   Date:  \u003Cbr>Once complete, fax this form, along with supporting documentation (chart notes, labs, etc.) back to EmpiRx Health at (551)-359-7177. Completed forms are required for full review. For questions please call ( 877)-  225-1669.\u003Cbr>This form is based on standard criteria and may not be applicable to all patients and plans and additional information or clarification may be required to evaluate requests. This form is intended for the purpose of obtaining new or continued prescription treatment for the above member.\u003Cbr>Origination Date: 09/2023\u003Cbr>Implementation Date: 07/2021 Page 1 of 1 |  |  |  |  |  |  |  |  |","cbCaikk7bvleKHmn","https://ap.wps.com/l/cbCaikk7bvleKHmn","pdf",718417,"English","# Patient Information\n## Prescriber Information\n## Medication Details and Clinical Questions\n## Prior Therapies and Clinical Documentation\n## Attestation and Submission Instructions","[{\"question\":\"What is the purpose of this clinical review form?\",\"answer\":\"It allows the pharmacy benefit manager to review the requested medication use for coverage. Submission does not guarantee approval, and documentation is required.\"},{\"question\":\"What information must be completed for patient and prescriber details?\",\"answer\":\"The form requires patient information (name, DOB, date, request ID/client IDs) and prescriber information (name, specialty, office address, phone/fax, NPI/DEA).\"},{\"question\":\"What documentation is required when submitting requests?\",\"answer\":\"Submit chart notes and relevant clinical information, including lab values. All requests require documentation, and include supporting rationale and clinical literature when applicable.\"}]","EmpiRx Health, LLC - Clinical Review Policy Approval Date - Version 1 | PDF",1789632466]