[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283758-105":53,"doc-detail-283758-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","specialty-drug-prior-authorization-form-20180417","Specialty Drug - Prior Authorization Form - 20180417","","Specialty Drug prior authorization form used to collect patient, prescriber, and insurance details needed for review. Captures patient demographics (name, address, contact, allergies, birth date, sex, weight/height/BSA), physician and practice credentials, and insurance coverage information for primary/secondary plans and PBM data. Includes required diagnosis fields with ICD-9/ICD-10 coding, patient evaluation questions about current use, treatment duration, outcomes, and prior therapies. Requests the rationale and pertinent clinical information and lists medication, strength, directions, quantity, and refills, with a physician signature.",{"@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/specialty-drug-prior-authorization-form-20180417/283758/",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/specialty-drug-prior-authorization-form-20180417/283758.png","ImageObject",442,249,{"name":88,"@type":89},"Angel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required for the prior authorization request?","Question",{"text":108,"@type":109},"The form requires patient demographics, prescriber details, insurance information (including PBM card data), and the diagnosis with an ICD-9/ICD-10 code. It also asks for clinical rationale and pertinent clinical information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What questions does the form ask under patient evaluation?",{"text":113,"@type":109},"It asks whether the member is currently treated with the medication, the duration on treatment, whether there was a positive outcome, and details of previous treatments and outcomes.",{"name":115,"@type":106,"acceptedAnswer":116},"What should be submitted with the physician rationale?",{"text":117,"@type":109},"The form states a decision cannot be made without a copy of pertinent lab results and/or current clinical progress notes, alongside the rationale and required clinical information.","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},283758,1790204245,{"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":20,"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},687207412472,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Send To: 􀀁 Envolve  \nDate:    \nDate Medication Required:   \nShip to: 􀀁 Physician 􀀁 Patient’s Home 􀀁 Other    \nPhone: (866) 399-0928  \nFax: (866) 399-0929 Prior Authorization Form  \nSpecialty Drug  \n\n| Patient Name:   Address:   City:   State:   Zip:  Home Phone: (  )   -  Work Phone: (  )   -  Cell Phone: (  )   -  Patient Soc. Sec \\#:   Allergies:  Date of Birth:   / /  Sex: 􀀁 Male 􀀁Female Weight   􀀁lbs 􀀁kg Height:   BSA:   m² 􀀁See attached demographic sheet | Physician Name:   State Lic \\#  DEA \\#   NPI \\#   Specialty:   Practice Name/Hospital:   Address:   City:   State:   Zip:   Physician’s Ph: (  )   -  Physician’s Fax: (  )   -  Nurse/Key Office Contact:   |\n| --- | --- |\n\n\n| \u003Cbr>INSURANCE INFORMATION (Complete or Attach Copies of cards) |  |  |  |\n| --- | --- | --- | --- |\n| Primary Insurance:  | Secondary Insurance:  | Rx Card (PBM):  | Cardholder First Name:   |\n| City:  State:  | City:  State:  | PBM BIN:   | Last Name:   |\n| Plan \\#:   | Plan \\#:   | City:  State:  | Employer:   |\n| Group \\#:   | Group \\#:   | Group \\#:   | ID \\#:   |\n| Phone: (  )   -  | Phone: (  )   -  | Phone: (  )   -  | Group \\#:   |\n\n\n| \u003Cbr>DIAGNOSIS (Required) |\n| --- |\n| What is the ICD 9 / ICD 10 code?   |\n| \u003Cbr>PATIENT EVALUATION |\n| 1. Is the member currently treated with this medication?\u003Cbr>􀀃 Yes; if yes, please continue\u003Cbr>􀀃 No; if no, please continue to question \\#4\u003Cbr>2. How long has the patient been on treated with this medication:   􀀃 years 􀀃 months\u003Cbr>3. Has the patient had a positive outcome? 􀀃 Yes 􀀃 No\u003Cbr>4. Please indicate previous treatments and outcomes?\u003Cbr>Drug Name (include strength and dosage) Dates of Therapy Reason for Discontinuation 1. 2. 3. 4. NOTE: confirmation of use will be made from member history on file; prior use of preferred drugs is part of the exception criteria\u003Cbr>5. Please state Rationale for Request / Pertinent Clinical Information (Required for all prior authorizations)\u003Cbr>**NOTE: We can NOT make a decision without a copy of pertinent lab results and/or the current clinical progress notes-Thank You** |\n\n\n| MEDICATION | STRENGTH | DIRECTIONS | QUANTITY | REFILLS |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n\nPhysician’s Signature:   􀀁 DAW (Dispense as Written Date / /   \nIMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.","cbCaiejfeduRTfL6","https://ap.wps.com/l/cbCaiejfeduRTfL6","pdf",309012,"English","# Patient and Prescriber Information\n## Insurance Information\n## Diagnosis and Patient Evaluation\n## Medication Details\n## Physician Signature and Notice","[{\"question\":\"What information is required for the prior authorization request?\",\"answer\":\"The form requires patient demographics, prescriber details, insurance information (including PBM card data), and the diagnosis with an ICD-9/ICD-10 code. It also asks for clinical rationale and pertinent clinical information.\"},{\"question\":\"What questions does the form ask under patient evaluation?\",\"answer\":\"It asks whether the member is currently treated with the medication, the duration on treatment, whether there was a positive outcome, and details of previous treatments and outcomes.\"},{\"question\":\"What should be submitted with the physician rationale?\",\"answer\":\"The form states a decision cannot be made without a copy of pertinent lab results and/or current clinical progress notes, alongside the rationale and required clinical information.\"}]","Specialty Drug - Prior Authorization Form - 20180417 | PDF",1789618807]