Us Script Prior Form PDF Details

As a writer, it's important to be familiar with the different types of screenplay formats. While each producer may have their own preference, there is one format that is generally accepted as the standard - Us Script Prior Form. In this article, you will learn what Us Script Prior Form is, and some of its key features. You'll also find out why it's so popular among producers.

This article provides information about us script prior form. Our recommendation is that you look at this information before you begin filling out the PDF.

QuestionAnswer
Form NameUs Script Prior Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessure scripts prior auth, medication prior form, surescripts prior authorization form pdf, surescripts prior authorization form

Form Preview Example

MEDICATION PRIOR AUTHORIZATION REQUEST FORM

Sunshine State Health Plan, Florida

(Do Not Use This Form for Biopharmaceutical Products*)

FAX this completed form to 866-399-0929

OR Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA 93711

Call 800-460-8988 to request a 72-hour supply of medication.

I. Provider Information

 

 

II. Member Information

 

 

 

 

 

 

 

 

 

 

Prescriber name (print):

 

 

Member name:

 

 

 

 

 

 

 

 

 

 

Prescriber Specialty:

 

 

Identification number:

 

 

 

 

 

 

 

 

 

 

 

Fax:

 

Phone:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

Office Contact Name:

 

 

Medication allergies:

 

 

 

 

 

 

 

III. Drug Information (One drug request per form)

 

 

 

Drug name and strength:

 

Dosage form:

Dosage interval (sig):

Qty per Day:

 

 

 

 

 

 

 

 

Diagnosis relevant to THIS request:

 

 

 

 

 

 

 

 

 

 

 

 

Expected length of therapy:

 

 

 

 

 

 

 

 

 

 

 

 

Medication History for this Diagnosis

 

 

 

 

 

A. Is member currently treated on this medication?

 

 

 

 

 

yes; How Long?_______________ [go to item B]

no

[skip items B & C; go to item D]

 

 

 

 

 

 

 

 

B. Is this request for continuation of a previous approval?

 

 

 

 

 

yes

[go to item C]

no

[skip item C; go to item D]

 

 

 

 

 

 

C. Has strength, dosage, or quantity required per day increased or decreased?

 

 

 

yes

[go to item D]

no

[skip item D; indicate rationale for continuation in Section IV and submit form]

 

 

 

 

 

 

 

D. Please indicate previous treatment and outcomes below.

 

 

 

 

 

Drug Name

 

 

Dates of Therapy

 

 

Reason for Discontinuation

 

(include strength and dosage)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Sunshine State Health Plan Preferred Drug List (PDL) is available on the Sunshine State Health Plan website at www.sunshinestatehealth.com .

IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)

Appropriate clinical information to support the request on

Provider Signature:

Date:

the basis of medical necessity must be submitted.

 

 

 

 

 

US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)

*Contact Caremark at 800-237-2767 for Biopharmaceutical Products.

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