Get Prior Authorization Form - Speciality Drug - The Co-operators

Filling out the Prior Authorization Form for speciality drugs, such as ®, is an important step in accessing necessary treatments. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring a smooth and efficient process.

Follow the steps to seamlessly complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Begin by completing Part 1 - Patient Information. Fill in the group name, account number, certificate number, and the plan member's details including full name, address, date of birth, and relationship to the plan member.
3. Move to Part 2 - Physician Information. Provide the physician's full name, address, telephone number, specialty, and fax number. Also, enter the requested drug’s name, DIN, strength, expected duration of therapy, and anticipated monthly cost.
4. Detail the diagnosis and stage of the disease, and list all previous medications and therapies used for treatment, including their strength, frequency, and duration. Also, state the outcomes of these treatments.
5. If applicable, specify the affected area related to hyperhidrosis. Ensure that all information provided is accurate and truthful.
6. Proceed to the physician's signature section, where the physician must sign and date the form, certifying that the information is complete and accurate.
7. In Part 3 - Patient/Guardian Authorization, fill out the patient or legal guardian’s name and telephone number. The patient or legal guardian should sign and date this section to authorize the information disclosure.
8. Once all sections are completed, you may save changes, download a copy of the form, print it out, or share it as needed.

Start filling out the Prior Authorization Form online and take the first step towards obtaining your treatment.