Healthcare PDE Review Form

Healthcare PDE Review Form

Patient Information

Patient Name:

Date of Birth:     Gender: Male Female Other

Insurance / Coverage

Policy Number:     Group Number:

Prescription Drug Event (PDE) Details

Please provide the PDE records you request to be reviewed. List each event with as much detail as available. For multiple items, attach additional pages and supporting documentation.

Reason for Review / Discrepancy Checklist

Indicate the primary reason(s) for requesting PDE review (check all that apply).

Incorrect dosage or directions
Incorrect quantity dispensed
Incorrect days supply
Unauthorized fill or not authorized by prescriber
Duplicate claim / duplicate fill
Billing or enrollment error
Other (explain below)

Supporting Information

Documents submitted with this request (check all that apply):

Prescription label(s)
Copy of written prescription
Pharmacy receipt or invoice
Medical record or prior authorization
Other supporting documentation

Authorization and Certifications

I authorize the plan, pharmacy, prescriber, and their agents to disclose and release any prescription drug event records, claims data, and clinical information necessary to investigate the items listed above. This authorization includes copies of pharmacy dispensing records, NDC level transaction detail, prescriber orders, and payment/adjustment documentation.

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that knowingly submitting false information may be subject to civil or criminal penalties and may invalidate the review request.

I understand that the review may result in confirmation, modification, or reversal of one or more PDE records and that any refund or adjustment will be processed in accordance with applicable plan and pharmacy policies. I further authorize disclosure of results to the subscriber and other parties as allowed by law for the purpose of resolution.

Authorization expiration date: . If no date is provided, this authorization expires 12 months from the date of signature.

Privacy Acknowledgment

By signing below, I acknowledge receipt of the privacy practices governing the use and disclosure of my protected health information in connection with this review. I understand my rights to revoke this authorization in writing except to the extent that action has already been taken in reliance on it.

Attestation

I attest that I am the patient named above or that I am the legally authorized representative of the patient. If signing as a representative, I certify that I have the authority to act on behalf of the patient and to authorize release of the requested records.

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