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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:
Required Field.
Required Field.
Required Field.
Invalid email address.
Member Information
Member Name:
Required Field.
Member Number:
Required Field.
Number Required.
Phone Number:
Required Field.
Date of Birth:
Required Field
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Effective Date:
Required Field.
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RadDatePicker
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Calendar
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Medication Information
Drug Name:
Required Field.
Dose:
Required Field.
Quantity:
Required Field.
Refill(s):
Required Field.
PLEASE LIST OTHER MEDICATIONS CURRENTLY PRESCRIBED:
Drug List:
Diagnosis:
Comments:
Physician Information
Member PCP:
Required Field.
Prescribing Physician's Name:
Required Field.
Prescribing Physician's Phone Number:
Required Field.
Prescribing Physician's Fax Number:
Prescribing Physician's Email:
Required Field.
Required Field.
Invalid email address.
Pharmacy Information
Pharmacy Name:
Required Field.
Pharmacy Phone Number:
Required Field.
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.