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Medication Exception/Prior Authorization Request Form
Fax this form and supporting chart notes to (503) 3468351Patient Information
Last Name:First Name:ID#:Phone #:Date of Birth:Email:Address:
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What is medication exceptionprior authorization request?
Medication exception/prior authorization request is a request to an insurance company or healthcare provider asking for approval to cover a medication that is not typically covered or requires additional approval before being prescribed.
Who is required to file medication exceptionprior authorization request?
Patients, physicians, or pharmacists may be required to file a medication exception/prior authorization request depending on the insurance company's policies.
How to fill out medication exceptionprior authorization request?
To fill out a medication exception/prior authorization request, one must provide detailed information about the patient, their medical history, the prescribed medication, and the reason for needing an exception to the standard coverage policy.
What is the purpose of medication exceptionprior authorization request?
The purpose of a medication exception/prior authorization request is to ensure that a prescribed medication is necessary and appropriate, especially when it deviates from the standard list of covered medications.
What information must be reported on medication exceptionprior authorization request?
Information such as patient demographics, medical history, prescribed medication details, diagnosis, healthcare provider information, and justification for the medication exception must be reported on a medication exception/prior authorization request.
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