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It includes sections for standard, date of service, and urgent criteria, along with HCPCS/CPT/CDT coding and clinical justification to support medical necessity. The form also captures prescription drug diagnosis, medication, dosing schedule, quantities, current treatment status, prior services, and provider attestation, with an administrative area for plan completion.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/florida-state-prior-authorization-request-form/283845/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/florida-state-prior-authorization-request-form/283845.png","ImageObject",442,249,{"name":88,"@type":89},"Connor ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required when submitting this prior authorization request form?","Question",{"text":108,"@type":109},"All applicable information and documentation must be included. Incomplete forms are returned for additional information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form handle standard versus urgent prior authorization requests?",{"text":113,"@type":109},"It provides checkboxes for Standard, Date of Service, and Urgent. For urgent requests, the provider must certify that the standard review timeline may seriously jeopardize the member’s life or health.",{"name":115,"@type":106,"acceptedAnswer":116},"What details are needed for prescription drug prior authorization?",{"text":117,"@type":109},"The form requests diagnosis name and code, medication requested, strength, dosing schedule and therapy length, quantity or limits, whether the patient is currently treated, treatment start date (if applicable), medical reasons for selecting the medication, and any other medications used in combination.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283845,1790482607,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},687207022233,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Prior Authorization Form for Medical Procedures, Courses of Treatment, or Prescription Drug Benefits  \nIf you have questions about our prior authorization requirements, please refer to CVS Caremark at 1-866-814-5506 All of the applicable information and documentation is required. Incomplete forms will be returned for additional information.  \n1. PRIORITY:  \n\n| [ ] | a. Standard |  |\n| --- | --- | --- |\n| [ ] | b. Date of Service | Services scheduled for this date: |\n| [ ] | c. Urgent | Provider certifies that applying the standard review time frame may seriously jeopardize the life or health of the member |\n\n2. PATIENT INFORMATION:  \n\n| a. Name (First): | b. Last: |  |  | c. MI: |  | d. DOB(mm/dd/yyyy): |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| e. Gender: [ ] Male [ ] Female |  | f. Height: |  |  | g. Weight: |  |  |\n| h. Address: |  | i. City, State, Zip: |  |  | j. Phone: |  |  |\n| k. Health Plan ID \\#: |  |  | l. Group \\#: |  |  |  |  |\n\n3. ORDERING PHYSICIAN/CLINIC INFORMATION:  \n\n| a. Name: | b. TIN/NPI\\#: | c. Specialty: | d. Contact Name: |\n| --- | --- | --- | --- |\n| e. Clinic Name: |  | f. Clinic Address: |  |\n| g. City, State, Zip: |  | h. Phone: | i. Fax or email: |\n\n4. RENDERING PHYSICIAN/CLINIC/FACILITY/PHARMACY INFORMATION: [ ] Check if same as 3.  \n\n| a. Name: | b. TIN/NPI\\#: | c. Specialty: | d. Contact Name: |\n| --- | --- | --- | --- |\n| e. Physician/Clinic/Facility/Pharmacy Name: |  | f. Address: |  |\n| g. City, State, Zip: |  | h. Phone: | i. Fax or email: |\n\n5. REQUESTED MEDICAL PROCEDURE/COURSE OF TREATMENT/DEVICE INFORMATION:  \n\n| a. Service Type: |\n| --- |\n| b. Setting/CMS POS Code: Outpatient [ ] Inpatient [ ] Home [ ] Office [ ] *Other [ ] |\n| c. *Please specify if other: |\n\n6. HCPCS/CPT/CDT CODES  \n\n| a. Latest ICD Code | b. HCPCS/CPT/CDT Code | c. Code Description | d. Medical Reason |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\nOther Clinical Information – Include/attach clinical/office notes, laboratory information, imaging reports, and any guiding documentation to support medical necessity. If this is an out-of-network request, please provide an explanation.  \n7. OTHER SERVICES (SEE INSTRUCTIONS)  \n\n| a. Type of Service: | b. Name of Therapy/Agency: |\n| --- | --- |\n\n69O-161.011  \nOIR-B2-2180 New 12/16  \nCVS Caremark Specialty Prior Authorization 800 Biermann Court Mount Prospect, IL 60056 Phone 1-866-814-5506 Fax 1-866-249-6155  \n75-42254A 053122  \nPrior Authorization Form for Medical Procedures, Courses of Treatment, or Prescription Drug Benefits If you have questions about our prior authorization requirements, please refer to CVS Caremark at 1-866-814-5506  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n| c. Units/Volume/Visits Requested: | d. Frequency/Length of Time Needed: |  | e. Initial [ ] Extension [ ] Previous Authorization \\#: |\n| f. Additional Comments: |  |  |  |\n\n8. PRESCRIPTION DRUG  \n\n| a. Diagnosis name and code: |  |  |  |\n| --- | --- | --- | --- |\n| b. Medication Requested | c. Strength | d. Dosing Schedule (including length of therapy) | e. Quantity Per Month or Quantity Limits |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n| f. Is the patient currently treated with requested medication(s): [ ] Yes [ ] No If yes, When was treatment with the requested medication started? |  |  |  |\n| g. Explain the medical reasons for the requested medications, including an explanation for selecting these medications over alternatives: |  |  |  |\n| h. List any other medications patient will use in combination with requested medication: |  |  |  |\n\n9. PREVIOUS SERVICES/THERAPY (INCLUDING DRUG, DOSE, DURATION, AND REASON FOR DISCONTINUING PREVIOUS THERAPY)  \n\n| a. | Date Discontinued |\n| --- | --- |\n| b. | Date Discontinued |\n| c. | Date Discontinued |\n\nAdditional Information – Please attach and submit any progress notes, lab data, discharge summaries, or other guiding documentation to support discontinuation of previous therapy and initiation of thera","cbCaioZRH6VYeQmL","https://ap.wps.com/l/cbCaioZRH6VYeQmL","pdf",190069,"English","# Priority\n# Patient Information\n# Ordering Physician/Clinic Information\n# Rendering Physician/Clinic/Facility/Pharmacy Information\n# Requested Medical Procedure/Course of Treatment/Device Information\n# HCPCS/CPT/CDT Codes\n# Other Clinical Information\n# Other Services\n# Prescription Drug\n# Previous Services/Therapy\n# Attestation","[{\"question\":\"What information is required when submitting this prior authorization request form?\",\"answer\":\"All applicable information and documentation must be included. Incomplete forms are returned for additional information.\"},{\"question\":\"How does the form handle standard versus urgent prior authorization requests?\",\"answer\":\"It provides checkboxes for Standard, Date of Service, and Urgent. For urgent requests, the provider must certify that the standard review timeline may seriously jeopardize the member’s life or health.\"},{\"question\":\"What details are needed for prescription drug prior authorization?\",\"answer\":\"The form requests diagnosis name and code, medication requested, strength, dosing schedule and therapy length, quantity or limits, whether the patient is currently treated, treatment start date (if applicable), medical reasons for selecting the medication, and any other medications used in combination.\"}]","Florida State - Prior Authorization Request Form | PDF",1789620802]