Futurescripts General Prior Auth Form – Fill Out and Use This PDF

Futurescripts General Prior Auth Form is a form that allows you to authorize Futurescripts.com to access your accounts on third-party websites, including payment information and personal data.

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Futurescripts General Prior Auth Form PDF 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.

Question	Answer
Form Name	Futurescripts General Prior Auth Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	57
Avg. time to fill out	11 min 39 sec
Other names	futurescripts prior authorization, futurescripts form, future scripts prior authorization form, future scripts fax form

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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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filling out bcbs federal prior urgent authorization forms part 1

Write the information in Drug, Name, dose, frequency Duration, of, therapy, include, dates Currently, prescribed and Yes, NoYes, NoYes, NoYes, No

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