Get Special Authorization Request Form - Alberta Blue Cross

Filling out the Special Authorization Request Form for Alberta Blue Cross can seem complex, but this guide will provide step-by-step instructions to help you navigate the process with ease. By carefully completing this form online, you can ensure that your request is processed efficiently and accurately.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient information section. Include the patient's last name, first name, initial, date of birth, Alberta personal health number, street address, city, province, postal code, and identification/client/coverage number.
3. Complete the prescriber information section by providing the prescriber's last name, first name, initial, street address, professional association registration (choose from CPSA, CARNA, ADA+C, ACP or other), registration number, phone number, fax number, city, province, and postal code. Ensure the fax number is included, as it is mandatory for the request.
4. Indicate the criteria for coverage of based on the patient's condition, whether they are intolerant to statins, have contraindications, or are not achieving target LDL levels.
5. In the NEW requests section, provide the diagnosis, details regarding previous STATIN use, and other relevant information about cardiovascular risk factors by checking the appropriate boxes.
6. For renewal requests, indicate the response to therapy and understand that renewal is necessary only if the special authorization approval has lapsed.
7. Once completed, include the prescriber’s signature and date. Then, forward the request to Alberta Blue Cross at the provided address or fax number.
8. After submitting the request, do not mail or re-fax it, as redundancy may complicate processing.
9. Finally, save changes, download, print, or share the completed form as needed.

Start completing your Special Authorization Request Form online today for expedited processing!