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The Medicaid Pharmacy Prior Authorization Form Colorado

The Medicaid Pharmacy Prior Authorization Form Colorado

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Review the prior authorization criteria in Appendix P at https //www. PRIOR AUTHORIZATION FORM Phone 1-800-424-5725 Fax 1-800-424-5881 Request Date / PATIENT INFORMATION LAST NAME FIRST NAME MEDICAID ID NUMBER DATE OF BIRTH PRESCRIBER INFORMATION STREET ADDRESS STATE CITY PHONE NUMBER ZIP FAX NUMBER NPI NUMBER DEA NUMBER DRUG INFORMATION DRUG REQUESTED STRENGTH QUANTITY FREQUENCY OF DOSING DIAGNOSIS METHOD OF DIAGNOSIS IF APPLICABLE FAILED MEDICATIONS CONTRAINDICATIONS/ALLERGIES CURRENT...
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