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Get IL 6000 IL ADHD 0808 2009-2022

is required for preauthorization consideration. For formulary information and to download additional forms, please visit www.bcbsil.com Today’s Date: PATIENT INFORMATION Patient Name (First): Last: Patient Address: M: City, State, Zip DOB (mm/dd/yyyy): Patient Telephone: INSURANCE INFORMATION BCBS ID Number: Group Number: PHYSICIAN/CLINIC INFORMATION Prescriber Name: Physician NPI#: Specialty: Clinic Name: Clinic Address: City, State, Zip: Phone #: Contact Name: Secure Fax #: .

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