General_Request_Form_F14.pdf.png
37 Downloads
0 0

Download this Express Scripts Prior Authorization Form that is designed to be provided to physicians to provide patient information as well, prescription information so that Express Scripts will be able to fill medications prescriptions by mail in 1-3 month amounts of medication. The amount will be determined according Doctor’s instructions and patient need. Once the form is received by Express Scripts and reviewed, permitted medications will be sent to the patient by mail.

How To Write

Step 1 – Section 1 – Patient Information –

  • Patient information must be provided:
  • Patient First Name
  • Patient Last Name
  • Patient ID#
  • Patient’s DOB mm/dd/yyyy
  • Patient Telephone Number

Step 2 – Section 2 – Prescriber Information –

  • Prescriber Name
  • Prescriber DEA/NP – Required Information
  • Prescriber Phone
  • Prescriber Fax
  • Prescriber Address, State, Zip Code

Step 3 – Section 3 – Diagnosis –

  • Prescriber must provide:
  • Diagnosis
  • ICD Code
  • Please indicate which drug and strength is being requested
  • Quantity Requested for how many days supply of requested medications
  • Other Medications/Therapies and Reasons for Failure and/or any other information the physician feels it may be important to review

Step 4 – Section 4 – Prescribing Physician Signature –

  • Prescriber Signature
  • Date
  • Office Contact Name
  • Office Telephone Number
  • Read all information at the bottom of the form
  • Fax completed form to  1-877-329-3760 or for Urgent Service 1-800-753-2851

 

Preview

Adobe PDF

MS Word

Rich Text