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The form gathers prior therapies tried and reasons for discontinuation, contraindications or intolerances, supporting laboratory/test results, high-risk medication acknowledgment for patients 65+, and quantity limit justifications with day-based quantities and rationale.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/prior-authorization-request-form-page-1-of-2/288972/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/prior-authorization-request-form-page-1-of-2/288972.png","ImageObject",442,249,{"name":42,"@type":43},"Aditya","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-07","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required under Member Information?","Question",{"text":63,"@type":64},"The form requests member name, insurance ID, date of birth, and address/contact details.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What clinical details must be provided for the medication request?",{"text":68,"@type":64},"It asks for the patient’s diagnosis with ICD-10 codes, prior medications tried with reasons for inadequate response or discontinuation, contraindications/intolerance details, and supporting labs or test results.",{"name":70,"@type":61,"acceptedAnswer":71},"How are quantity limit requests justified?",{"text":72,"@type":64},"The form requires the quantity requested per day and the reason for exceeding plan limits, including options such as titration/loading dose, dose-alternating schedules, non-commercially available strength, or other medically necessary justifications.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},288972,1789999310,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":121,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":26},962085564549,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Prior Authorization Request Form (Page 1 of 2)  \nDO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED  \n\n| Member Information (required) |  |  | Provider Information (required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | Provider Name: |  |  |  |\n| Insurance ID\\#: |  |  | NPI\\#: |  | Specialty: |  |\n| Date of Birth: |  |  | Office Phone: |  |  |  |\n| Street Address: |  |  | Office Fax: |  |  |  |\n| City: | State: | Zip: | Office Street Address: |  |  |  |\n| Phone: |  |  | City: | State: |  | Zip: |\n| Medication Information (required) |  |  |  |  |  |  |\n| Medication Name: |  |  | Strength: |  | Dosage Form: |  |\n| 􀂉 Check if requesting brand |  |  | Directions for Use: |  |  |  |\n| 􀂉 Check if request is for continuation of therapy |  |  |  |  |  |  |\n| Clinical Information (required) |  |  |  |  |  |  |\n| What is the patient’s diagnosis for the medication being requested?   ICD-10 Code(s):   |  |  |  |  |  |  |\n| What medication(s) has the patient tried and had an inadequate response to? (Please specify ALL medication(s)/strengths tried, length of trial, and reason for discontinuation of each medication) |  |  |  |  |  |  |\n| What medication(s) does the patient have a contraindication or intolerance to? (Please specify ALL medication(s) with the associated contraindication to or specific issues resulting in intolerance to each medication) |  |  |  |  |  |  |\n| Are there any supporting labs or test results? (Please specify) |  |  |  |  |  |  |\n| Use of High Risk Medications (HRMs) in the elderly (applies on patients ≥ 65 years ONLY) :\u003Cbr>\"Use of High Risk Medications in the Elderly\" is measure 238 of the Centers for Medicare & Medicaid Services Physician Quality Reporting System.\u003Cbr>Does the provider acknowledge that this drug has been identified by the Centers for Medicare and Medicaid Services as a high risk medication in the 65 and older population? 􀂉 Yes 􀂉 No\u003Cbr>Does the provider wish to proceed with the originally prescribed medication? 􀂉 Yes 􀂉 No |  |  |  |  |  |  |\n| Quantity limit requests:\u003Cbr>What is the quantity requested per DAY?  \u003Cbr>What is the reason for exceeding the plan limitations?\u003Cbr>􀂉 Titration or loading-dose purposes\u003Cbr>􀂉 Patient is on a dose-alternating schedule (e.g. , one tablet in the morning and two tablets at night, one to two tablets at bedtime)\u003Cbr>􀂉 Requested strength/dose is not commercially available\u003Cbr>􀂉 There is a medically necessary justification why the patient cannot use a higher commercially available strength to achieve the same dosage and remain within the same dosing frequency. Please specify:  \u003Cbr>􀂉 Patient requires a greater quantity for the treatment of a larger surface area [Topical applications only]\u003Cbr>􀂉 Other:   |  |  |  |  |  |  |\n\nY0043_ N00016915_C  \nPrior Authorization Request Form (Page 2 of 2)  \nDO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED  \nAre 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________________________________________________________________________________________________________________  \nPlease note: This request may be denied unless all required information is received.  \nIf the patient is not able to meet the above standard prior authorization requirements, please call 1-888-791-7255.  \nFor urgent or expedited requests please call 1-888-791-7255.  \nThis form may be used for non-urgent requests and faxed to 1-844-403-1028.  \nNONDISCRIMINATION NOTICE  \nKaiser Foundation Health Plan of Colorado (Kaiser Health Plan) complies with applicable Federal and state civil rights laws and does not discriminate , exclude people or treat them less favorably on the basis of race, color, national origin (including limited English proficiency and primary language) ,","cbCaigzggz7jzr1M","https://ap.wps.com/l/cbCaigzggz7jzr1M","pdf",597571,"English","# Member Information\n## Medication Information\n## Clinical Information\n## High Risk Medications in the Elderly\n## Quantity Limit Requests\n# Provider and Review Instructions","[{\"question\":\"What information is required under Member Information?\",\"answer\":\"The form requests member name, insurance ID, date of birth, and address/contact details.\"},{\"question\":\"What clinical details must be provided for the medication request?\",\"answer\":\"It asks for the patient’s diagnosis with ICD-10 codes, prior medications tried with reasons for inadequate response or discontinuation, contraindications/intolerance details, and supporting labs or test results.\"},{\"question\":\"How are quantity limit requests justified?\",\"answer\":\"The form requires the quantity requested per day and the reason for exceeding plan limits, including options such as titration/loading dose, dose-alternating schedules, non-commercially available strength, or other medically necessary justifications.\"}]","Prior Authorization Request Form - Page 1 of 2 | PDF",1789634316]