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Requires complete and legible patient, prescriber, and pharmacy details, including HIPAA-compliant fields. Collects medication name/strength, dosing directions, quantity and day supply, ICD-10 diagnosis codes, prior therapies and failure reasons, and benefit type selection. Includes an expedited review attestation, documentation confirmation, prescriber signature and date, plus a confidentiality 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patient’s authorized representative details if applicable.",{"name":116,"@type":107,"acceptedAnswer":117},"What medication and clinical details must be provided?",{"text":118,"@type":110},"Medication name and strength, directions for use, quantity and day supply, therapy type (new or continuation with start date and duration), ICD-10 diagnosis codes, patient height and weight, and any previously tried and failed agents with dates and 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determination.Please fill out all sections completely and legibly.Documentation is required for all requests.  \n\n| □ Request to expedite review  \u003Cbr>Request Date:   |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| If the prescriber attests that applying the standard turnaround time could seriously jeopardize the life,health,or safety of the member or others,due to the member's psychological  \u003Cbr>state,or in the opinion of a practitioner with knowledge of the member's medical or behavioral condition,would subject the member to adverse health consequences without the care  \u003Cbr>or treatment that is the subject of the request,please mark above the request to expedite this review process.   |  |  |  |  |  |  |  |  |\n| Patient Information   |  |  |  |  |  |  |  |  |\n| This section must be filled out completely to ensure HIPAA compliance   |  |  |  |  |  |  |  |  |\n| First Name:   |  |  | Last Name:   |  |  | Phone Number:   |  |  |\n| Address:   |  |  |  | City:   |  | State:   |  | Zip Code:   |\n| Date of Birth:   |  | □ Male□ Female   |  | Member ID:   |  |  |  |  |\n| Patient's Authorized Representative (if applicable):   |  |  |  | Authorized Representative Phone Number:   |  |  |  |  |\n| Prescriber Information   |  |  |  |  |  |  |  |  |\n| First Name:   |  |  | Last Name:   |  |  | Specialty:   |  |  |\n| Address:   |  |  |  | City:   |  | State:   |  | Zip Code:   |\n| NPI Number(individual):   |  |  |  | Phone Number:   |  |  |  |  |\n| Fax Number (in HIPAA compliant area):   |  |  |  |  |  |  |  |  |\n| Dispensing Pharmacy Information   |  |  |  |  |  |  |  |  |\n| Pharmacy Name:   |  |  |  | Pharmacy Fax Number (in HIPAA compliant area):   |  |  |  |  |\n| Medication and Medical Information   |  |  |  |  |  |  |  |  |\n| Medication Name and Strength:   |  |  |  |  | □ Dispense as written □ Generic substitution permitted*  \u003Cbr>*default is generic substitution permitted   |  |  |  |\n| Directions for Use:   |  |  |  |  | Quantity:   |  |  | Day Supply:   |\n| □ New Therapy   | □ Continuation of Therapy-Start Date:_____   _   |  |  |  | Duration of Therapy:   |  |  |  |\n| ICD 10 codes(s)and diagnosis for use of medication:   |  |  |  | Patient Height(in/cm):   |  |  | □ Pharmacy Benefit  \u003Cbr>□ Medical Benefit   |  |\n|  |  |  |  | Patient Weight(Ib/kg):   |  |  |  |  |\n| If the patient has tried other medication(s)for this condition,please provide a list of previously tried and failed agents,including dates and reason(s)for failure   |  |  |  |  |  |  |  |  |\n| Has documentation (i.e.,chart notes,pertinent lab values,medical history,etc.)been provided?   □Yes □ No   |  |  |  |  |  |  |  |  |\n| Prescriber attests that the provided information is complete and accurate and understands that RxBenefits,Inc.reserves the right to perform an audit requesting  \u003Cbr>the medical information necessary to verify accuracy at any time.  \u003Cbr>Date:  \u003Cbr>Prescriber Signature:   |  |  |  |  |  |  |  |  |\n| Confidentiality Notice:The documents accompanying this transmission contain confidential health information that is legally privileged.If you are not the intended recipient,you are  \u003Cbr>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 informationin  \u003Cbr>error,please notify the sender immediately (via return FAX)and arrange for the return or destruction of these documents.   |  |  |  |  |  |  |  |  |\n\nl  \nUpdated on 05.15.2025","cbCaimQaQDwtKIGc","https://ap.wps.com/l/cbCaimQaQDwtKIGc","pdf",325323,"English","# Medication Prior Authorization Request Form\n## Expedited Review Request\n## Patient Information\n## Prescriber Information\n## Dispensing Pharmacy Information\n## Medication and Medical Information\n## Documentation Attestation and Signature\n## Confidentiality Notice","[{\"question\":\"Who can request expedited medication prior authorization review, and what must they attest?\",\"answer\":\"The prescriber attests that standard turnaround could seriously jeopardize the member’s life, health, or safety due to the member’s psychological state, or based on the practitioner’s knowledge of the medical or behavioral condition.\"},{\"question\":\"What information is required under Patient Information?\",\"answer\":\"Complete patient identity details such as first and last name, phone number, address (city, state, zip), date of birth, sex, and member ID; also include the patient’s authorized representative details if applicable.\"},{\"question\":\"What medication and clinical details must be provided?\",\"answer\":\"Medication name and strength, directions for use, quantity and day supply, therapy type (new or continuation with start date and duration), ICD-10 diagnosis codes, patient height and weight, and any previously tried and failed agents with dates and reasons.\"}]","Medication Prior Authorization Request Form | PDF"]