Future Script Details

The Futurescripts General Prior Auth Form is now available for download on our website. The form was designed to streamline the prior authorization process by allowing healthcare providers to quickly and easily submit requests for certain medications. Please note that this form is only for medications that do not require an individualized treatment plan. If you are seeking prior authorization for a medication that requires an individualized treatment plan, please contact your local Futurescripts representative.

This basic guide will let you find out how much time it'll take you to complete futurescripts general prior auth form, the number of pages it has, and a few additional unique details about the PDF.

QuestionAnswer
Form NameFuturescripts General Prior Auth Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprior authorization requirements for 2020, script template, futurescripts prior authorization, future scripts forms

Form Preview Example

General Prior Authorization Form

ONLY COMPLETED REQUESTS WILL BE REVIEWED

Gender Edit

Quantity Edit

Age Edit

Prior Authorization

Drug Requested _____________________________

Quantity ___________________

(one drug per form only)

(qty. edit 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

No

 

 

 

Yes

No

 

 

 

Yes

No

 

 

 

Yes

No

a. Is the patient currently not compliant on the regimen specific to the diagnosis?

Yes

No

N/A

Please add any other supporting medical information that may be useful in the decision-making process:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

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

06/2010 PA004-GEN

Provider Communication

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