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Includes clinical criteria required to support approval, including treatment context, acute recurrent diabetic gastroparesis status, prior oral metoclopramide trial outcomes, and swallowing difficulty. Provides attestation and confidentiality notice, with submission instructions for faxing and mailing to Prime Therapeutics’ program.",{"@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/phi-prior-authorization-request-form-urgent/287645/",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/phi-prior-authorization-request-form-urgent/287645.png","ImageObject",442,249,{"name":88,"@type":89},"Grenda","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-25","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to complete this PHI prior authorization request?","Question",{"text":108,"@type":109},"The form requires member details, prescriber information, patient representative contact info when applicable, and medication dispensing details including dose, frequency, therapy duration/refills, and specific treatment dates.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What clinical questions must be answered to support prior authorization?",{"text":113,"@type":109},"It asks whether the drug is part of a sponsored clinical trial regimen, whether the patient has acute recurrent diabetic gastroparesis, whether oral metoclopramide was tried and failed, and whether the patient has difficulty swallowing.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should the completed form be sent?",{"text":117,"@type":109},"Fax the form to 800-424-7640 and mail requests to Prime Therapeutics Management Prior Authorization Program, Attn: CP-4201, P.O. Box 64811, St. Paul, MN 55164-0811.","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},287645,1790294461,{"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":73,"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},7971474921005,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Instructions: Please fill out all applicable sections completely and legibly. Attach any additional documentation that is important for the review (e.g., chart notes or lab data, to support the authorization request) . Information contained in this form is Protected Health Information under HIPAA.  \n URGENT  \n\n| MEMBER INFORMATION |  |\n| --- | --- |\n| LAST NAME: | FIRST NAME: |\n| PHONE NUMBER: | DATE OF BIRTH: |\n| STREET ADDRESS: |  |\n| CITY: | STATE: ZIP CODE: |\n| PATIENT INSURANCE ID NUMBER: |  |\n\n MALE  FEMALE HEIGHT (IN/CM):   WEIGHT (LB/KG):   ALLERGIES:    \nIF YOU ARE NOT THE PATIENT OR THE PRESCRIBER, YOU WILL NEED TO SUBMIT A PHI DISCLOSURE AUTHORIZATION FORM WITH THIS REQUEST WHICH CAN BE FOUND AT THE FOLLOWING LINK: PRIMETHERAPEUTICS.COM/NOPP  \nPATIENT’S AUTHORIZED REPRESENTATIVE (IF APPLICABLE):   AUTHORIZED REPRESENTATIVE’S PHONE NUMBER:    \n\n| PRESCRIBER INFORMATION |  |\n| --- | --- |\n| LAST NAME: | FIRST NAME: |\n| PRESCRIBER SPECIALTY: | EMAIL ADDRESS: |\n| NPI NUMBER: | DEA NUMBER: |\n| PHONE NUMBER: | FAX NUMBER: |\n| STREET ADDRESS: |  |\n| CITY: | STATE: ZIP CODE: |\n| REQUESTOR (if different than prescriber) : | OFFICE CONTACT PERSON: |\n\n\n| MEDICATION OR MEDICAL DISPENSING INFORMATION |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| MEDICATION NAME: |  |  |  |  |  |  |  |\n| DOSE/STRENGTH: |  |  | FREQUENCY: |  |  | LENGTH OF\u003Cbr>THERAPY/REFILLS: | QUANTITY: |\n|  |  | NEW THERAPY |  |  | RENEWAL IF RENEWAL: DATE THERAPY INITIATED: |  |  |\n| DURATION OF THERAPY (SPECIFIC DATES): |  |  |  |  |  |  |  |\n\nContinued on next page  \n\n| 1. HAS THE PATIENT TRIED ANY OTHER MEDICATIONS FOR THIS CONDITION? |  |  | YES (if yes, complete below) |  | \u003Cbr>NO |\n| --- | --- | --- | --- | --- | --- |\n| MEDICATION/THERAPY (SPECIFY DRUG NAME AND DOSAGE) : | DURATION OF THERAPY (SPECIFY DATES) : | RESPONSE/REASON FOR\u003Cbr>FAILURE/ALLERGY: |  |  |  |\n| 2. LIST DIAGNOSES: |  | ICD-10: |  |  |  |\n| □ Diabetic gastroparesis\u003Cbr>□ Other diagnosis:   ICD-10  |  |  |  |  |  |\n| 3. REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL INFORMATION TO SUPPORT A PRIOR AUTHORIZATION. |  |  |  |  |  |\n| Clinical Information:\u003Cbr>Is this drug being prescribed to this patient as part of a treatment regimen specified within a sponsored clinical trial? □ Yes □ No\u003Cbr>Does the patient have acute, recurrent diabetic gastroparesis? □ Yes □ No\u003Cbr>Has the patient previously tried and failed oral metoclopramide (tablets and/or oral solution)?\u003Cbr>□ Yes □ No please submit documentation\u003Cbr>Does the patient have difficulty swallowing? □ Yes □ No |  |  |  |  |  |\n| Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review? |  |  |  |  |  |\n|  |  |  |  |  |  |\n| Please note: Not all drugs/diagnosis are covered on all plans. This request may be denied unless all required information is received. |  |  |  |  |  |\n| ATTESTATION: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.\u003Cbr>Prescriber Signature or Electronic I.D. Verification:   Date:   |  |  |  |  |  |\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 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 (via return FAX) and arrange for the return or destruction of these documents. |  |  |  |  |  |\n\nFAX THIS FORM TO: 800-424-7640  \nMAIL REQUESTS TO: Prime Therapeutics Management Prior Authorization Program  \nAttn: CP-4201  \nP.O","cbCaijkCF6d04oPR","https://ap.wps.com/l/cbCaijkCF6d04oPR","pdf",210934,"English","# Member Information\n# Prescriber Information\n# Medication or Medical Dispensing Information\n# Clinical Information for Prior Authorization\n# Attestation and Confidentiality Notice\n# Submission Instructions","[{\"question\":\"What information is required to complete this PHI prior authorization request?\",\"answer\":\"The form requires member details, prescriber information, patient representative contact info when applicable, and medication dispensing details including dose, frequency, therapy duration/refills, and specific treatment dates.\"},{\"question\":\"What clinical questions must be answered to support prior authorization?\",\"answer\":\"It asks whether the drug is part of a sponsored clinical trial regimen, whether the patient has acute recurrent diabetic gastroparesis, whether oral metoclopramide was tried and failed, and whether the patient has difficulty swallowing.\"},{\"question\":\"Where should the completed form be sent?\",\"answer\":\"Fax the form to 800-424-7640 and mail requests to Prime Therapeutics Management Prior Authorization Program, Attn: CP-4201, P.O. Box 64811, St. Paul, MN 55164-0811.\"}]","PHI Prior Authorization Request Form - Urgent | PDF",1789632571]