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The form documents whether the requested drug is supplied from practitioner and/or office stock and billed as part of a practitioner service “incident to a practitioner’s service.” It includes fields for drug and diagnosis information, contact details, comments, and a signed attestation that provided information is accurate and documentation is available for health plan review.",{"@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/prescriber-criteria-form-prescriber-services-2026-pa-fax-bd-13-v1-010126-coverage-determination/288533/",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/prescriber-criteria-form-prescriber-services-2026-pa-fax-bd-13-v1-010126-coverage-determination/288533.png","ImageObject",442,249,{"name":88,"@type":89},"Ben Jamin","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Where should the signed faxed form be sent for prior authorization processing?","Question",{"text":108,"@type":109},"Fax the signed forms to CVS Caremark at 1-855-633-7673.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form define the “incident to a practitioner’s service” requirement?",{"text":113,"@type":109},"The form asks whether the requested drug is being supplied from practitioner and/or office stock and billed as part of a practitioner service, meaning the drug is furnished “incident to a practitioner’s service.”",{"name":115,"@type":106,"acceptedAnswer":116},"What attestation is made by the prescriber signature on the form?",{"text":117,"@type":109},"By signing, the prescriber (or authorized representative) attests that the information is accurate and true as of the date and that supporting documentation is available for health plan review if requested.","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},288533,1790170610,{"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":9,"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":4},2336478466772,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","| Prescriber Criteria Form\u003Cbr>Prescriber Services 2026 PA Fax BD-13 v1 010126.docx\u003Cbr>Drugs Given Incident To Prescriber Services\u003Cbr>Coverage Determination |\n| --- |\n| This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CVS Caremark at 1-855-633-7673. Please contact CVS Caremark at 1-866-785-5714 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Drugs Given Incident To Prescriber Services. |\n\nDrug Name:  \n\n| Patient Name: |  |  |\n| --- | --- | --- |\n| Patient ID: |  |  |\n| Patient DOB: | Patient Phone: |  |\n| Prescriber Name: |  |  |\n| Prescriber Address: |  |  |\n| City: | State: | Zip: |\n| Prescriber Phone: | Prescriber Fax: |  |\n| Diagnosis: | ICD Code(s): |  |\n\n\n| Please circle the appropriate answer for each question. |  |  |  |\n| --- | --- | --- | --- |\n| 1 | Is the requested drug being supplied from the practitioner and/or office stock supply and billed as part of a practitioner service (i.e. , the drug is being furnished “incident to a practitioner’s service”)? | Yes | No |\n\n\n| Comments: |  |\n| --- | --- |\n|  |  |\n\n\n| By signing this form, I attest that the information provided is accurate and true as of this date and that the documentation supporting this information is available for review if requested by the health plan. |\n| --- |\n| Prescriber (or Authorized) Signature:   Date:  |","cbCairjODCxSXsDU","https://ap.wps.com/l/cbCairjODCxSXsDU","pdf",184264,"English","# Coverage Determination\n## Submission and HIPAA attestation\n## Practitioner and patient information\n## Drug and diagnosis details\n## Incident to criteria question\n## Comments and signature","[{\"question\":\"Where should the signed faxed form be sent for prior authorization processing?\",\"answer\":\"Fax the signed forms to CVS Caremark at 1-855-633-7673.\"},{\"question\":\"How does the form define the “incident to a practitioner’s service” requirement?\",\"answer\":\"The form asks whether the requested drug is being supplied from practitioner and/or office stock and billed as part of a practitioner service, meaning the drug is furnished “incident to a practitioner’s service.”\"},{\"question\":\"What attestation is made by the prescriber signature on the form?\",\"answer\":\"By signing, the prescriber (or authorized representative) attests that the information is accurate and true as of the date and that supporting documentation is available for health plan review if requested.\"}]","Prescriber Criteria Form - Prescriber Services 2026 PA Fax BD-13 v1 010126 - Coverage Determination | PDF",1789633601]