12529E (2020-09)
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



 


GROUP INSURANCE – HEALTH CLAIMS
PRIOR AUTHORIZATION REQUEST




PLEASE READ THE INSTRUCTIONS ON THE BACK OF THIS FORM.
     
  
   
 
Signature of physician: Date:
               





Signature of member:
Date:

 
  
  
  
   
   
 
YYYY MM DD
Yes
No
If so
  
PATIENT SUPPORT
PROGRAM


A
PATIENT IDENTIFICATION


g

Yes  

 
No


g
Yes 
No

B
DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION


C
ATTENDING PHYSICIAN SECTION









CONTINUED ON THE BACK


.
PRINT
NEW REQUEST
C
ATTENDING PHYSICIAN SECTION


PRIOR MEDICATION OR TREATMENT
  


PRESCRIPTION RENEWAL

YYYY MM DD
MEDICATION OR TREATMENT NAME
OUTCOME








  

  



  
  
TREATMENT PERIOD








YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Page 2 of 2
DIAGNOSIS
 
 

INFORMATION RELATING TO CHRONIC HEPATITIS C GENOTYPE 1 OR 1A
  
  
INFORMATION RELATING TO CHRONIC HEPATITIS C GENOTYPE 2 OR 3
  






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
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 
 
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

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

D
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 

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