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Aetna pre cert form AETNA BETTER HEALTH Pharmacy prior authorization form Patient Information Patient Name Member ID# Sex (circle) M DOB Home Phone: F Prescriber Name NPI#(required) Office Address City, State, Zip Code

Prior request form Indiana Health Coverage Programs Prior Authorization Request Form Traditional Hoosier Healthwise Check the box of the plan in which the member is enrolled. Healthy Indiana Plan Care Select Advantage Traditional Anthem Hoosier Healthwise Anthem HHW SFHN MDwise Hoosier Healthwise MHS Hoosier Healthwise Anthem HIP MDwise HIP MHS HIP Advantage Care Select MDwise Care Select P 800-269-5720 F 800-689-2759 P 866-408-7187 F 866-406-2803 P 800-291-4140 F 800-747-3693 See www. mdwise. org P 877-647-4848 F 866-912-4245 P 866-398-1922 F 866-406-2803 P 800-784-3981 F 800-689-2759 P 866-440-2449 F 877-822-7186 Please complete all appropriate fields. Patient Information Requesting Provider Information Medicaid ID/RID NPI DOB Tax ID Patient Name Service Location Code Address Provider Name City/State/Zip Rendering Provider Information Patient/Guardian Phone Ordering Physician NPI PMP Name PMP NPI Name PMP Phone Medical Diagnosis Use of ICD-9 Diagnostic Code is Required Dx1 Dx2 Dx3 Phone Fax Please check the requested assignment category below DME Purchased Rented Home Health Hospice Dates of Service Start Stop Inpatient Physical Therapy Observation Speech Therapy Office Visit Transportation Occupational Therapy Other Outpatient Procedure/ Service Codes Modifier s Requested Service Preparer s Information Taxonomy POS Units Dollars Notes PLEASE NOTE Your request MUST include medical documentation to be reviewed for medical necessity. mdwise. org P 877-647-4848 F 866-912-4245 P 866-398-1922 F 866-406-2803 P 800-784-3981 F 800-689-2759 P 866-440-2449 F 877-822-7186 Please complete all appropriate fields. Patient Information Requesting Provider Information Medicaid ID/RID NPI DOB Tax ID Patient Name Service Location Code Address Provider Name City/State/Zip Rendering Provider Information Patient/Guardian Phone Ordering Physician NPI PMP Name PMP NPI Name PMP Phone Medical Diagnosis Use of ICD-9 Diagnostic Code is Required Dx1 Dx2 Dx3 Phone Fax Please check the requested assignment category below DME Purchased Rented Home Health Hospice Dates of Service Start Stop Inpatient Physical Therapy Observation Speech Therapy Office Visit Transportation Occupational Therapy Other Outpatient Procedure/ Service Codes Modifier s Requested Service Preparer s Information Taxonomy POS Units Dollars Notes PLEASE NOTE Your request MUST include medical documentation to be reviewed for medical necessity.

Pharmacy authorization form Pharmacy Prior Authorization Form INSTRUCTIONS Complete this form in its entirety. Any incomplete sections will result in a delay in processing. We review requests for prior authorization based on medical necessity only. We will notify the provider and the member s pharmacy of our decision. To help us expedite your authorization requests please fax all the information required on this form to 1 800 359 5781. Allow us at least 24 hours to review this request. If you have questions regarding the prior authorization request call us at 1 800 454 3730. If we approve the request payment is still subject to all general conditions of Amerigroup including current member eligibility other insurance and program restrictions. We will notify the provider and the member s pharmacy of our decision. To help us expedite your authorization requests please fax all the information required on this form to 1 800 359 5781. Allow us at least 24 hours to review this request. If you have questions regarding the prior authorization request call us at 1 800 454 3730. The pharmacy is authorized to dispense up to a 72 hour supply while awaiting the outcome of this request. Please contact the member s pharmacy. Access our website at providers. amerigroup.com to view the preferred drug list. If we approve the request payment is still subject to all general conditions of Amerigroup including current member eligibility other insurance and program restrictions. Allow us at least 24 hours to review this request. If you have questions regarding the prior authorization request call us at 1 800 454 3730. The pharmacy is authorized to dispense up to a 72 hour supply while awaiting the outcome of this request. Please contact the member s pharmacy. Access our website at providers. amerigroup*com to view the preferred drug list. An ICD/Diagnosis code is required for all requests. An HCPCS billing code is required for all medical injectable/oncology requests. If the billing facility is different from the requesting physician the billing facility information will need to be completed* Member Information Last name First name MI Member s place of residence Home Nursing Facility Administration site Office Outpatient facility Amerigroup ID Height Date Of Birth Sex circle one F M Medication Information Drug name and strength requested SIG dose frequency and duration HCPCS billing code Diagnosis and/or indication ICD code Has the member tried other medications Drug s name and strength to treat this condition Date range of use SIG dose and frequency Yes. Provide this information in the area to the right. You may be asked to provide Did the member experience any of the below supporting documentation such as Adverse reaction Inadequate response Other Copies of medical records Briefly describe details of adverse reaction inadequate Office notes response or other in the space provided below. Complete FDA Medwatch form No* Explain why not PF ALL 0037 12 June 2012 Describe medical necessity for nonpreferred medication s or for prescribing outside of FDA labeling List all current medications including dose and frequency Other pertinent information Diagnostic Studies and/or Laboratory Tests Performed List all tests done within the past 30 days that are related to diagnosis of medication requested* Labs Diagnostic tests Test Date Result Procedure Prescriber Information NPI required City Address where service was rendered ZIP code Telephone number Office contact name DEA/License State Fax number Contact direct phone number Billing Facility Information Name Address NPI /Tax ID required Pharmacy Information Pharmacy NPI Signature I certify that the information provided is accurate and complete to the best of my knowledge and I understand that any falsification omission or concealment of material may be subject to civil or criminal liability.

Medco health medicare part d p... 35045 *35045* Medicare Part D Prior Authorization Request Form (page 1 of 2) Please complete both pages and return to Medco by fax at 1-800-837-0959. Please indicate if you are requesting urgent processing

Humana prior authorization for... PRIOR AUTHORIZATION REQUEST FORM EOC ID Administrative Product - Universalr r rPhone 800-555-2546 Fax back to 1-877-486-2621 HUMANA INC manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. For Medicare PFFS members prior authorization is not required for Part B-covered medications. The information below is needed for a Part B versus Part D determination for these members. Patient Name NA Prescriber Name NA Member/Subscriber Number Fax Date of Birth Office Contact Group Number NPI Address City State ZIP Phone Tax ID Specialty/facility name if applicable rExpedited/Urgent Please read if expedited request By signing below I certify that applying the standard 72-hour review time frame may seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function* Drug Name Directions/SIG Signature Qty Please attach any pertinent medical history or information for this patient that may support approval* Please answer the following questions and sign Q1. Please provide J-code if applicable Q3. Is the medication being requested for use in an ongoing investigational trial Yes No. r Q5. Please list therapeutic alternatives previously used with start/end dates and outcome Prescriber Signature Date This telecopy transmission contains confidential information belonging to the sender that is legally privileged* This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient you are hereby notified that any disclosure copying distribution or action taken in reference to the contents of this document is strictly prohibited* If you have received this telecopy in error please notify the sender immediately to arrange for the return of this document. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. For Medicare PFFS members prior authorization is not required for Part B-covered medications. Please note any information left blank or illegible may delay the review process. For Medicare PFFS members prior authorization is not required for Part B-covered medications. The information below is needed for a Part B versus Part D determination for these members. Patient Name NA Prescriber Name NA Member/Subscriber Number Fax Date of Birth Office Contact Group Number NPI Address City State ZIP Phone Tax ID Specialty/facility name if applicable rExpedited/Urgent Please read if expedited request By signing below I certify that applying the standard 72-hour review time frame may seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function* Drug Name Directions/SIG Signature Qty Please attach any pertinent medical history or information for this patient that may support approval* Please answer the following questions and sign Q1.

Express scripts prior authoriz... This form is based on Express Scripts standard criteria and may not be applicable to all patients Amida Care may require additional information beyond what is specifically requested. Fax completed form to 1- 800- 357- 9577 If this an URGENT request please call 1- 800- 417- 8164 Prior Authorization Form and Patient Information Prescriber Information Patient First Name Patient La...

Kentucky cremation authorizati... Date Cremation Received Cremation Number Name of person performing cremation COMMONWEALTH OF KENTUCKY OFFICE OF THE ATTORNEY GENERAL PRE-NEED CREMATION AUTHORIZATION FORM CR-3 11-02 NMS INC. CARE CREMATION SERVICE 1014 EASTLAND DRIVE LEXINGTON KY 40505 Phone 859 388-9442 Fax 859 388-9443 In making a pre-need authorization for the cremation of your remains you are the authorizing agent. Please read carefully the items below. In the statement titled Final Disposition you must indicate your desire pertaining to the disposition of your cremated remains. After you have read and completed each item your signature is required on the item titled Signature of Authorizing Agent. IDENTIFICATION Please Print All Information On This Form Name Address City State Zip Home Telephone Age Sex Does the Decedent Authorizing Agent have any infectious or contagious disease YES NO If yes please explain Mechanical or radioactive devices or implants in the Authorizing Agent may create a hazardous condition when placed in a cremation chamber. Page 1 of 4 other device that could be explosive YES NO If any such device s exist the next class of authorizing agent is responsible for disclosing their existence at the time of death. Has the Decedent Authorizing Agent been treated with therapeutic radionuclides such as Strontium 89 or any other treatment that would result in residual radioactive material remaining as part of the Decedent Authorizing Agent s remains YES If yes what was the treatment Date treatment was last administered The Decedent Authorizing Agent shall carefully read and understand the following statements before signing this authorization* The decedent authorizing agent shall complete the segment directing the final disposition of his/her cremated remains. CARE CREMATION SERVICE will not conduct any cremation nor accept a body for cremation unless it has a cremation authorization form signed by the Decedent Authorizing Agent clearly stating the final disposition* All cremations are performed individually. It is unlawful to cremate the remains of more than one individual within the same cremation chamber at the same time. The consumer may choose cremation without choosing embalming services. However if the crematory does not have a refrigerated holding facility it cannot accept human remains for anything other than immediate cremation* The consumer is not required to purchase a casket for the purpose of cremation* a casket or an alternative cremation container for cremation* If an alternative container is provided it must meet the following standards 1 be composed of readily combustible materials suitable for cremation 2 be able to be closed to provide a complete covering for the human remains 3 be resistant to leakage or spillage and 4 be rigid enough to support the weight of the deceased* including opening if necessary and in the event there is leakage or damage SERVICE may refuse to accept the Decedent Authorizing Agent s remains for the purpose of cremation or refrigeration* Type of casket or alternative container selected Due to the nature of the cremation process any personal possessions or valuable materials such as dental gold or jewelry as well as any body prostheses or dental bridgework that are left with the Decedent Authorizing Agent and not removed from the casket or alternative container prior to cremation will be destroyed or will otherwise not be recoverable.

Envision rx prior authorizatio... PRIOR AUTHORIZATION REQUEST FORM EOC ID: EnvisionRxOptions General Prior Auth Formr rPhone: 855-872-0005 Fax back to: 877-503-7231 r r ENVISION RX OPTIONS manages the pharmacy drug benefit for your

Vendor ach payment authorizati... THE SENIOR ALLIANCE Vendor ACH Authorization Form SECTION I Vendor Information Company Name: Address: State: Zip: Accounts Receivable Contact: Phone: E-Mail: SECTION II Authorization Agreement I (we)

Instructions for form f 11075... DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11075 (10/11) STATE OF WISCONSIN DHS 107.10(2), Wis. Admin. Code FORWARDHEALTH PRIOR AUTHORIZATION / PREFERRED DRUG

Pa medical command authorizati... MEDICAL COMMAND AUTHORIZATION FORM ALS Service Affiliate # Last Name (ALS Practitioner) Street Address City E-mail Address Check One: EMT-Paramedic PHRN HP Physician Other Calendar Year First MI State

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