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It also gathers diagnosis codes and medication specifics such as strength, dosing schedule, quantity, route, expected therapy length, and prior therapy and testing attestation. 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This form is for prospective, concurrent, and retrospective reviews.  PLEASE INCLUDE APPLICABLE CHART NOTES, LABORATORY RESULTS and RADIOLOGY FINDINGS Incomplete forms will be returned for additional information. The following documentation is required for preauthorization consideration.  \nPATIENT INFORMATION Today’s Date:  \n\n| Patient Name (First): | Last: |  | M: | DOB (mm/dd/yyyy): |\n| --- | --- | --- | --- | --- |\n| Patient Address: |  | City, State, Zip: | Patient Telephone: |  |\n\nINSURANCE INFORMATION  \n\n| Member ID Number: | Group Number: |\n| --- | --- |\n\nPHYSICIAN/CLINIC INFORMATION  \n\n| Prescriber Name: | Physician NPI\\#: |  | Specialty: |  | Contact Name: |\n| --- | --- | --- | --- | --- | --- |\n| Clinic Name: |  | Clinic Address: |  |  |  |\n| City, State, Zip: |  | Phone \\#: |  | Secure Fax \\#: |  |\n\n\n| Patient’s Diagnosis (ICD Code plus Description): |  |\n| --- | --- |\n| Medication Requested: Strength: |  |\n| Dosing Schedule (Frequency): Quantity per Month: |  |\n| Route of Administration: Expected Length of Therapy |  |\n| 1. Has the patient been on this medication in the past 6 months? Yes No Start date: \u003Cbr>2. Has the patient tried and had an inadequate treatment response or intolerance to first line agents? Yes No\u003Cbr>Please list: \u003Cbr>3. Is the requested drug being used for an FDA-approved indication OR an indication supported in the compendia of current literature (examples: AHFS, Micromedex, current accepted guidelines)? Yes No\u003Cbr>4. Has the patient had appropriate laboratory and/or genetic testing to support the diagnosis? Yes No\u003Cbr>5. Renewals only: Has the patient improved while on this treatment? Yes No\u003Cbr>6. Have chart notes been attached to this request? (Required) Yes No |  |\n| Please fax or mail this form to:\u003Cbr>Archimedes , LLC\u003Cbr>278 Franklin Rd. Ste 245\u003Cbr>Brentwood , TN 37027\u003Cbr>TOLL FREE\u003Cbr>Fax: 866-491-6971 Phone: 888-504-5563 | CONFIDENTIALITY NOTICE: This communication is intended only for the use of the individual entity to which it is addressed and may contain information that is privileged or confidential. If the reader of this message isnot the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately by telephone at 888-504-5563 and return the original message to Archimedes via U.S. Mail. Thank you for your cooperation. |\n\nPLEASE INCLUDE APPLICABLE CHART NOTES, LABORATORY RESULTS and RADIOLOGY FINDINGS  \n©ARCHIMEDES 2024 V.OHY2024PA.1","cbCaitbR3HdgmjcX","https://ap.wps.com/l/cbCaitbR3HdgmjcX","pdf",157069,"English","# Patient Information\n# Insurance Information\n# Physician/Clinic Information\n# Diagnosis and Medication Details\n# Fax/Mail Submission Instructions","[{\"question\":\"Who is allowed to complete the Medication Preauthorization Request Physician Fax Form?\",\"answer\":\"Only the prescriber may complete the form.\"},{\"question\":\"What documentation must be included for preauthorization consideration?\",\"answer\":\"Include applicable chart notes, laboratory results, and radiology findings.\"},{\"question\":\"What key medication details does the form request?\",\"answer\":\"It collects the medication requested, strength, dosing schedule (frequency), quantity per month, route of administration, and expected length of therapy.\"}]","Medication Preauthorization Request Physician Fax Form | PDF"]