Greenshield Prescription Drug Form – Fill Out and Use This PDF

PRESCRIPTION DRUG

SPECIAL AUTHORIZATION REQUEST FORM

Dear Plan Member:

Please have the following Prescription Drug Special Authorization form completed in full by your physician. If you are eligible for coverage by another plan (public or private) please have doctor indicate below. Your request will be reviewed and evaluated by our Drug Special Authorization Department who will communicate the results to you. Should you have any questions, you may contact our Customer Service Centre at 1-888-711-1119. Please note: Incomplete and/or missing information may delay your request for processing.

SECTION 1 – PATIENT INFORMATION

Surname	Green Shield I.D. #		Employer Name
First Name	Date of Birth (Y/M/D)		Telephone Number
Street Address	City	Province		Postal Code

I hereby authorize any licensed physician/dentist, medical practitioner, hospital, clinic or medically related facility, to give to Green Shield Canada information regarding my health. I hereby authorize Green Shield Canada to exchange information with other parties as required, only when the information is needed to administer this benefit and/or to confirm the accuracy of this information.

Date _____________________________________________	Signature of Patient _________________________________________________
(If under 14 years of age, the signature of the plan member is required.)

SECTION 2 – PHYSICIAN INFORMATION

Physician Name		Physician Signature	Specialty	Date (Y/M/D)
Street Address			Telephone Number
City	Province	Postal Code	Fax Number

SECTION 3 – DRUG REQUESTED FOR EVALUATION

Product name/dose/duration and results of prior treatment:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Additional comments pertaining to medication/medical condition:

Please provide us with information on other coverage (provincial or private) as it pertains to this patient and medication:

Applied for coverage:

Yes

No

Approved

Denied

SECTION 4 – MAILING INSTRUCTIONS

Once completed, please return request along with any original paid “Official Pharmacy” receipts to:

Green Shield Canada

Drug Special Authorization Department

P.O. Box 1606, Windsor ON N9A 6W1

Forms can be faxed or emailed: Fax: 1-519-739-6483 or Toll Free: 1-866-797-6483 or Email: drugspecial.autho@greenshield.ca

THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN MEMBER.

Prescription Drug Special Autho EN (Rev. 2008-11)

RXDR