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certain plans and situations may require additional information beyond what is specifically requested.  \n[Additionalformsavailable:](Additionalformsavailable:www.express-scripts.com/pa)[www.express-scripts.com/pa](Additionalformsavailable:www.express-scripts.com/pa)  \nPatient Information  \nPatient First Name:    \nPatient Last Name:    \nPatient ID\\#:    \nPatient DOB:    \nPatient Phone \\#:   \n_  \nFax completed form to 1-877-251-5896 If this is an URGENT request, please call 1-800-417-8164  \nPrescriber Information  \nPrescriber Name:   Prescriber DEA/NPI (required):   Prescriber Phone \\#:   Prescriber Fax \\#:   Prescriber Address:    \nState:  Zip Code:    \nDiagnosis:  ICD Code:    \nPlease indicate which drug and strength is being requested:    \nQuantityRequested   for  dayssupply Other Medications/Therapies tried and reason(s) for failure and/or any other information the physician feels is important to the review:  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n\nPrescriberSignature:  Date:    \nOffice Contact Name:  Phone Number:    \nBased upon each patient’s prescription plan, additional questions may be required to complete the prior authorization process. If you have any questions about the process or required information, please contact our prior authorization team at the number listed on the top of this form.  \nPrior Authorization of Benefits is not the practice of medicine or a substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what medications are appropriate for the patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions.  \nThe document(s) accompanying this transmission may contain confidential health information. This information is intended only for the use of the individual or entity named above. 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 received this information in error, please notify the sender immediately and arrange for the return or destruction of the documents.","cbCaiuPdTAGkqjVg","https://ap.wps.com/l/cbCaiuPdTAGkqjVg","pdf",113500,"English","# Patient Information\n## Prescriber Information\n## Diagnosis and Requested Medication\n## Signature, Contact, and Notes","[{\"question\":\"What information does the form collect for the patient?\",\"answer\":\"It requests the patient’s first name, last name, patient ID, date of birth, and phone number.\"},{\"question\":\"What prescriber details are required?\",\"answer\":\"The prescriber section includes name, DEA/NPI (required), phone, fax, address, and signature with date.\"},{\"question\":\"How is the diagnosis and medication request documented?\",\"answer\":\"The form asks for diagnosis with ICD code and the specific drug and strength requested, along with quantity and days’ supply.\"}]","Prior Authorization Form - General Request Form | PDF",1789618804]