[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283898-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283898-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","general-drug-prior-authorization-form-confidentiality-notice-and-attestation","General Drug Prior Authorization Form - Confidentiality Notice and Attestation","","General Drug Prior Authorization Form for the West Virginia Medicaid Bureau for Medical Services under the Rational Drug Therapy Program. The template collects patient identifiers, prescriber details, and pharmacy information, and includes a confidentiality notice protected by law. It states that preauthorization for medical necessity does not guarantee payment, and that pharmaceutical samples are not considered in evaluating members’ medical conditions. The form also includes an attestation section requiring certification of medical necessity and access to medical/pharmacy records upon request.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/general-drug-prior-authorization-form-confidentiality-notice-and-attestation/283898/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/general-drug-prior-authorization-form-confidentiality-notice-and-attestation/283898.png","ImageObject",442,249,{"name":42,"@type":43},"Ava Thompson","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",14,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does the form collect about the patient?","Question",{"text":63,"@type":64},"It collects patient name, West Virginia Medicaid 11-digit ID, and date of birth (MM/DD/YYYY).","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What does the confidentiality notice require?",{"text":68,"@type":64},"It limits access to the named individual or entity, prohibits disclosure to other parties unless required by law, and instructs the intended recipient to destroy the information after its transmission purpose is fulfilled.",{"name":70,"@type":61,"acceptedAnswer":71},"What does the prescriber or pharmacist attest to when signing?",{"text":72,"@type":64},"The signature certifies the request is medically necessary, does not exceed the member’s medical needs, and is documented in medical records, with medical/pharmacy records available upon request.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283898,1789970212,{"code":4,"msg":82,"data":83},"success",[84,89,94,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},1649267921044,"https://us-avatar.wpscdn.com/avatar/1800007509477c92dfb?_k=1786009248482753345","General Drug Prior Authorization Form  \nWest Virginia Medicaid Bureau for Medical Services  \n[https://dhhr.wv.gov/bms/BMS%20Pharmacy/Pages/default.aspx](https://dhhr.wv.gov/bms/BMS%20Pharmacy/Pages/default.aspx)  \nRational Drug Therapy Program WVU School of Pharmacy PO Box 9511 HSCN Morgantown, WV 26506  \nFax: 1-800-531-7787  \nPhone: 1-800-847-3859  \nPatient Name (Last) (First) (M) WV Medicaid 11 Digit ID\\# Date of Birth (MM/DD/YYYY)  \nPrescriber Name (Last) (First) (MI)  \nPrescriber Address (Street) (City) (State) (Zip)  \n\n|  |  | West Virginia |  |\n| --- | --- | --- | --- |\n\nPrescriber 10-Digit NPI\\# Phone \\# (111-222-3333) Fax \\# (111-222-3333)  \nPharmacy Name (if applicable)  \nPharmacy Address (Street) (City) (State) (Zip)  \n\n|  |  | West Virginia |  |\n| --- | --- | --- | --- |\n\nPharmacy 10-Digit NPI\\# Phone \\# (111-222-3333) Fax \\# (111-222-3333)  \nConfidentiality Notice: This document contains confidential health information that is protected by law. This information is intended only for the use of the individual or entity named above. The intended recipient of this information should destroy the information after the purpose of its transmission has been accomplished or is responsible for protecting the information from any further disclosure. The intended recipient is prohibited from disclosing this information to any other party unless required to do so by law. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately by telephone at (800) 847-3859 and arrange for the return or destruction of these documents. Thank you.  \nImportant Notes: Preauthorization for medical necessity does not guarantee payment.  \nThe use of pharmaceutical samples will not be considered when evaluating the members' medical condition or prior prescription history for drugs that require prior authorization.  \nOther Pertinent Information.  \nAttestation: Your signature (manually or electronically) certifies that the above request is medically necessary, does not exceed the medical needs of the member, and is documented in your medical records. Medical/Pharmacy records must be made available upon request.  \nCheck here for electronic signature  \nPrescriber or Pharmacist Signature  \nDate:  \n(MM/DD/YYYY)","cbCaifNJUH60YM7w","https://ap.wps.com/l/cbCaifNJUH60YM7w","pdf",237523,"English","# Patient Information\n# Prescriber Information\n# Pharmacy Information\n# Confidentiality Notice\n# Important Notes\n# Attestation and Signatures","[{\"question\":\"What information does the form collect about the patient?\",\"answer\":\"It collects patient name, West Virginia Medicaid 11-digit ID, and date of birth (MM/DD/YYYY).\"},{\"question\":\"What does the confidentiality notice require?\",\"answer\":\"It limits access to the named individual or entity, prohibits disclosure to other parties unless required by law, and instructs the intended recipient to destroy the information after its transmission purpose is fulfilled.\"},{\"question\":\"What does the prescriber or pharmacist attest to when signing?\",\"answer\":\"The signature certifies the request is medically necessary, does not exceed the member’s medical needs, and is documented in medical records, with medical/pharmacy records available upon request.\"}]","General Drug Prior Authorization Form - Confidentiality Notice and Attestation | PDF",1789621738]