[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283921-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283921-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","prior-authorization-request-prescriber-fax-form","Prior Authorization Request - Prescriber Fax Form","","Prior authorization request prescriber fax form for prospective, concurrent, and retrospective medication reviews. Requires the prescriber to complete request priority (standard vs expedited/urgent) with today’s date and optional date of service. Captures patient and insurance identifiers, prescriber and clinic details including NPI, diagnosis ICD code, and the medication request with strength, dosing schedule, and monthly quantity. Requires attachment of supporting medical records and answers to clinical questions including prior therapies, safety concerns, diabetes formulary appropriateness, and combination medications.",{"@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-prescriber-fax-form/283921/",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-prescriber-fax-form/283921.png","ImageObject",442,249,{"name":42,"@type":43},"Aurelia","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-02","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who is allowed to complete the prior authorization fax form?","Question",{"text":63,"@type":64},"Only the prescriber may complete this form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What determines whether a request is standard or expedited/urgent?",{"text":68,"@type":64},"Expedited/urgent requires certification that waiting for a standard review could seriously harm the patient’s life, health, or ability to regain maximum function.",{"name":70,"@type":61,"acceptedAnswer":71},"What documentation is required for the request to be considered complete?",{"text":72,"@type":64},"Medical records including chart notes are required; incomplete forms are returned for additional information.","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},283921,1789622487,{"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":26,"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":80,"read_time":22},1099514068365,"https://ap-avatar.wpscdn.com/avatar/10000253d8d9f28188e?_k=1776742907772140068","PRIOR AUTHORIZATION REQUEST  \nPRESCRIBER FAX FORM  \nOnly the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews.  \nThe following documentation is REQUIRED. Incomplete forms will be returned for additional information. For formulary information [please visit](please visit www.myprime.com. Start saving)[ ](please visit www.myprime.com. Start saving)[www.myprime.com](please visit www.myprime.com. Start saving)[.](please visit www.myprime.com. Start saving)[ Start saving](please visit www.myprime.com. Start saving) time today by filling out this prior authorization form electronically. Visit [covermymeds.com](covermymeds.com) to begin using this free service.  \nWhat is the priority level of this request?  \n Standard review  \n Expedited/Urgent review – prescriber certifies that waiting for a standard review could seriously harm the patient’s life, health or ability to regain maximum function  \nToday’s Date:    \nPATIENT AND INSURANCE INFORMATION Date of Service (if differs from Today’s Date):    \n\n| Patient Name (First): | Last: |  | M: | DOB (mm/dd/yyyy): |\n| --- | --- | --- | --- | --- |\n| Patient Address: | City, State, Zip: |  | Patient Telephone: |  |\n| Member ID Number: |  | Group Number: |  |  |\n\nPRESCRIBER/CLINIC INFORMATION  \n\n| Prescriber Name: | Prescriber NPI\\#: |  | Specialty: |  | Contact Name: |\n| --- | --- | --- | --- | --- | --- |\n| Clinic Name: |  | Clinic Address: |  |  |  |\n| City, State, Zip: |  | Phone \\#: |  | Secure Fax \\#: |  |\n\nPLEASE ATTACH ANY ADDITIONAL INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST  \n\n| Patient’s Diagnosis-ICD code plus description: |  |\n| --- | --- |\n| Medication Requested: | Strength: |\n| Dosing Schedule: | Quantity per Month: |\n| For all requests:\u003Cbr>1. What is the patient’s weight?   (kg)\u003Cbr>2. Is the patient currently being treated with the requested agent? ................................ ................................ .......  Yes  No If yes, is the patient stable on the requested agent? ................................ ................................ ...............  Yes  No\u003Cbr>Are they at risk if therapy is changed? ................................ ................................ ..........................  Yes  No\u003Cbr>3. Is the request for an FDA-approved agent for diabetes mellitus? ................................ ................................    Yes  No If yes, has the prescriber stated that it is medically inappropriate for the patient to use a formulary alternative?................................ ................................ ................................ ................................ ..............  Yes  No\u003Cbr>4. Is the patient taking another medication in the same therapeutic class for treatment of the same indication? .  Yes  No If yes, will the other medication be discontinued before starting the requested medication? ..................  Yes  No\u003Cbr>5. Please list all reasons for selecting the requested medication, dosing schedule and quantity over alternatives (e.g.\u003Cbr>contraindications, allergies or history of adverse drug reactions to alternatives, lower dose tried) .  \u003Cbr>\u003Cbr>\u003Cbr>6. Please list other medications the patient will use in combination with the requested medication for treatment of this diagnosis.\u003Cbr>__________________________________________________________________________________________________\u003Cbr>__________________________________________________________________________________________________\u003Cbr>7. Please list all medications the patient has previously tried and failed for treatment of this diagnosis. (Please specify if the patient has tried brand-name products, generic products or over-the-counter products. )\u003Cbr>   Date(s):     Date(s):  \u003Cbr>   Date(s):     Date(s):  \u003Cbr>   Date(s):     Date(s):  \u003Cbr>***MEDICAL RECORDS INCLUDING CHART NOTES ARE REQUIRED FOR THIS REQUEST*** Please continue to the next page. |  |\n\n6110 HCSC PAST 0819 A Division of Health Care Service Corpor","cbCaijgcBWS8X7jf","https://ap.wps.com/l/cbCaijgcBWS8X7jf","pdf",232215,"English","# Prior authorization request\n## Request priority and dates\n## Patient and insurance information\n## Prescriber/clinic information\n## Diagnosis and medication requested\n## Clinical questions and medication history\n## Required documentation and submission","[{\"question\":\"Who is allowed to complete the prior authorization fax form?\",\"answer\":\"Only the prescriber may complete this form.\"},{\"question\":\"What determines whether a request is standard or expedited/urgent?\",\"answer\":\"Expedited/urgent requires certification that waiting for a standard review could seriously harm the patient’s life, health, or ability to regain maximum function.\"},{\"question\":\"What documentation is required for the request to be considered complete?\",\"answer\":\"Medical records including chart notes are required; incomplete forms are returned for additional information.\"}]","Prior Authorization Request - Prescriber Fax Form | PDF"]