Get Special Authorization Request - Empire Life - Empire

Filling out the SPECIAL AUTHORIZATION REQUEST form is an essential step in ensuring timely approval for medication under the health benefit program. This guide will walk you through the process of completing the form accurately and efficiently.

Follow the steps to complete your authorization request

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member name, group number, and patient name in the corresponding fields. Ensure that the certificate number, relationship to the member, and complete address details are accurate.
3. In the telephone number section, input the area code and phone number. Also, fill in the patient's date of birth using the specified format (YYYY/MM/DD).
4. Review the authorization statement regarding the exchange of information and provide your signature along with the date of signature in the designated areas.
5. For the physician's section, if applicable, ensure the physician prints their name, specialty qualification, address, and contact information clearly. The date and physician's signature must also be included.
6. Complete the drug requested for special authorization section by specifying the drug name, strength, diagnosis, and any additional details required, such as the duration of therapy.
7. If there are previous drugs prescribed for the patient's condition, detail the drug name, strength, reason for discontinuation, and duration of therapy in the specified fields.
8. Clearly indicate the reason for prescribing the requested drug by checking the relevant boxes and providing any necessary explanations or supporting documentation as required.
9. Provide any relevant medical information, if applicable, by checking the corresponding boxes and including lab results or functional class details, as necessary.
10. Lastly, indicate the site of drug administration by selecting the appropriate option and ensuring all sections of the form are completed before submission.
11. Once the form is filled out completely, you can save changes, download, print, or share the form as necessary.

Take action now and complete your SPECIAL AUTHORIZATION REQUEST online for efficient processing.