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It collects patient demographics and member/plan identifiers, detailed prescriber credentials, and requested medication information including strength, dosage form, quantity, day supply, and dosing directions. The form captures diagnosis and ICD-10 codes, brand request and allergy history, clinical information and drug history, and supporting evidence such as labs or contraindications. 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􀂅 Yes 􀂅 No\u003Cbr>If Yes, has the patient had a non-allergic reaction, therapeutic failure, or side effect with at least 2 generic manufacturers (if available) of the requested drug? 􀂅 Yes 􀂅 No If Yes, has a MedWatch form been submitted documenting the therapeutic failure or adverse outcome experienced? 􀂅 Yes 􀂅 No |  |  |  |  |\n| Clinical Information and History |  |  |  |  |\n| Drug Name | Strength | Dates of Use |  | Description of Adverse Reaction or Tried and Failed |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| Supporting information such as: lab values, contraindications, allergies, or any other information relevant to this request.\u003Cbr>DrugAllergies: Height: Weight:\u003Cbr>Other: |  |  |  |  |\n| 􀂅 Urgent (Complete this section ONLY if URGENT):\u003Cbr>By signing below, you are attesting that waiting for a standard decision could seriously harm the patient's life, health, or ability to regain maximum function.\u003Cbr>PRESCRIBER SIGNATURE REQUIRED Date:\u003Cbr>The Prescriber confirms the above information is accurate and can be verified by patient records. |  |  |  |  |\n| 􀂅 Non-Urgent (Complete this section ONLY if NON-URGENT):\u003Cbr>PRESCRIBER SIGNATURE REQUIRED Date:\u003Cbr>The Prescriber confirms the above information is accurate and can be verified by patient records. |  |  |  |  |\n\nInformation on this form is Protected Health Information and subject to all privacy and security regulations under HIPAA","cbCaikvIlUHM5339","https://ap.wps.com/l/cbCaikvIlUHM5339","pdf",239535,"English","# Prior Authorization Request Form\n## Form Use and Checklists\n## Patient Information\n## Prescriber Information\n## Medication Information and Quantity Limit Requests\n## Diagnosis, ICD-10, and Brand Request (DAW)\n## Clinical Information and History\n## Supporting Information\n## Urgent vs Non-Urgent Attestation and Signature","[{\"question\":\"Who can use this form?\",\"answer\":\"The form is to be used by prescribers only and requires a prescriber signature.\"},{\"question\":\"What patient information is required?\",\"answer\":\"It requires patient name, date of birth, phone number, address (city/state/zip), and member ID and plan name.\"},{\"question\":\"What must be completed for medication quantity limit requests?\",\"answer\":\"The form requires the requested medication, strength, dosage form, quantity, day supply, and directions, plus selection of applicable request types such as titration, tried-and-failed plans, dose consolidation limits, insulin total daily units, or other specified requests.\"}]","MedImpact Standard MRF 2023 rev3 - Prior Authorization Request Form | PDF"]