Pharmacy Prior Authorization Form


Community Care Associates, Inc.
PHARMACY DEPARTMENT
Fax: (313) 961-3116 Office: (313) 961-3100

Prior Authorization Form

Person Completing Form
Request Date:
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Contact Name: Contact Email:
    

Member Information
Member Name:  Member Number:   Phone Number: 
Date of Birth: 
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Effective Date: 
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Medication Information
Drug Name: 
Dose:  Quantity:  Refill(s): 
PLEASE LIST OTHER MEDICATIONS CURRENTLY PRESCRIBED:
Drug List:
Diagnosis:
Comments:

Physician Information
Member PCP: 
Prescribing Physician's Name: 
 Prescribing Physician's Phone Number: 
Prescribing Physician's Fax Number:
 Prescribing Physician's Email:
   

Pharmacy Information
Pharmacy Name: 
 Pharmacy Phone Number: 

Important Instructions
ALL PRIOR AUTHORIZATION'S WILL REQUIRE PROGRESS NOTES FROM PATIENT'S MEDICAL CHART FOR THE SAID DIAGNOSIS.

INCOMPLETION OF THIS FORM AND MISSING PROGRESS NOTES WILL DELAY THIS PROCESS.

The information in this telescopy, incluing any attachments, is confidential and may contain proprietary and/or priveledged information. It is intended soley for the use of intended recipient(s). Any disclosure, copying, distribution or any action taken in reliance upon this information by persons or entities other than the intended recipient is prohibited. If you receive this in error, please contact the sender at the above telephone number on this form.