Prior authorizations (PAs) are required by insurance companies for certain medications. Without a prior authorization, your health insurance may not cover your medication, and you will have to pay out of pocket. It usually takes approximately 30 minutes to fill out this form.
NOTE: There is an option at the bottom of the page to SAVE and continue later in case you need to obtain more information and complete the form at a later time.
If you would like to use a hard copy of this form, click here for a PDF. You may mail the form to our office, FAX it to 612-259-7665, or scan and email it to firstname.lastname@example.org (email may not be secure depending on how your email client is configured).
By submitting this form you are giving us permission to release pertinent information to your pharmacy.
Once we receive your completed form, we will process the prior authorization. Please allow your pharmacy one week to process. If the request is not approved, please contact your insurance company to find out why.
PATIENT AND INSURANCE INFORMATION
INSURANCE / THIRD PARTY INFORMATION REQUESTING THE PRIOR AUTHORIZATION
Your insurance company or the third party that covers pharmacy medications; this may be different than your health insurance member ID.
Name (ex. Express Scripts, Cooportunity Health, etc.) :
Please contact your pharmacy to and gather the following information:
Listed pharmacy where medication request was sent:
Please let the pharmacist know whether you are requesting a brand name product versus generic to ensure you get the right in NDC number.
Please note your pharmacy-related insurance ) may require you to fill out additional paperwork or forms for a prior authorization, so it may be a good idea to reach out to them as well.
Please list your PAST HISTORY of mental health-related medications. These are medications you are no longer taking.
MEDICATION #1 NAME
Please list your CURRENT mental health-related medications.
CURRENT MEDICATION #1 NAME