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  • ADHD Agents Quantity Limit Prior Authorization Form

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    Cathy Thompson
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    This document is a prior authorization form for ADHD agents that requires information such as the drug and quantity requested, patient details, prescribing physician details, provider specialty, diagnosis, medication history, and any additional supporting medical information. It notes that only completed requests will be reviewed and requests for off-label use require supporting literature.

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    This document is a prior authorization form for ADHD agents that requires information such as the drug and quantity requested, patient details, prescribing physician details, provider specialty, diagnosis, medication history, and any additional supporting medical information. It notes that only completed requests will be reviewed and requests for off-label use require supporting literature.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    3 views1 page

    ADHD Agents Quantity Limit Prior Authorization Form

    Uploaded by

    Cathy Thompson
    This document is a prior authorization form for ADHD agents that requires information such as the drug and quantity requested, patient details, prescribing physician details, provider specialty, diagnosis, medication history, and any additional supporting medical information. It notes that only completed requests will be reviewed and requests for off-label use require supporting literature.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    ADHD Agents Quantity Limit Prior Authorization Form

    ONLY COMPLETED REQUESTS WILL BE REVIEWED

    Drug Requested _____________________________

    Quantity _____units per ______Days

    (one drug per form only)

    Date: __________________________

    Patient ID#: ________________ DOB:___________

    Patient Name: _______________________________

    Provider NPI: _______________________________

    Prescribing Physician: _________________________

    Office Contact: ______________________________

    Office Fax #: _______________________________

    Office Phone: _______________________________

    ONLY COMPLETED REQUESTS WILL BE REVIEWED


    ***MEDICARE PART D ONLY: REQUESTS FOR OFF-LABEL USE REQUIRE SUPPORTING LITERATURE***

    1. PROVIDER SPECIALTY (specify all) _________________________________________________


    2. DIAGNOSIS FOR DRUG REQUESTED (specify all) ____________________________________
    3. MEDICATION HISTORY (Please list any previous or current therapy related to the diagnosis, using drug names and dates)
    Drug Name (dose and frequency)

    Duration of therapy (include dates)

    Currently prescribed

    Yes
    Yes
    Yes
    Yes

    No
    No
    No
    No

    Please add or attach any other supporting medical information and/or clinical trials that may be useful in the decision-making
    process including contraindications to medications related to the diagnosis:

    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    ____________________________________________________________________________________________
    FAX TO (888) 671-5285. YOUR OFFICE WILL RECEIVE A RESPONSE VIA FAX OR MAIL

    03/2011 PA030-ADHD QL

    Provider Communication

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