Medication Prior Authorization Request Form
1-844-477-8313
Provider Services
SunshineHealth.com
SH_ 1971
Type of Request:
Today’s Date:
I. MEMBER INFORMATION II. PRESCRIBER INFORMATION
*Name: *Name:
ID Number: Specialty:
Gender: *NPI or DEA Number:
*Date of Birth: *Phone:
Medication Allergies: *Fax:
Member’s Height: Office Contact Name:
Member’s Weight: kg lb. (select one)
III. ADMINISTRATION
Site of Administration: If other, specify:
If preferred administration site has a different address than the prescribing physician’s practice above, please
complete the following:
Name of Preferred Site of Administration or Home Infusion Company:
Contact Name: Phone: Fax: NPI#:
IV. DRUG INFORMATION (only ONE drug request per form)
*HCPCS (if buy and bill): *Drug Name:
*Strength: *Dosage Form:
*Directions for Use (sig):
*Therapy Start Date: *Therapy End Date:
V. DIAGNOSIS (as relevant to this request)
Diagnosis: *ICD10:
Date of Diagnosis: NOTE: Include diagnostic clinicals (labs, radiology, etc.).
VI. RATIONALE FOR REQUEST and PERTINENT CLINICAL INFORMATION
NOTE: Supporting documentation (such as office chart notes, lab results, prior therapy and other clinical information) is
REQUIRED for consideration of approval.
X Date:
Prescriber Signature
For a current listing of preferred products, visit SunshineHealth.com or contact Provider Services at 1-844-477-8313.
*REQUIRED FIELDS: PA requests with missing/incomplete required fields may be returned as an invalid request. Valid requests
also require appropriate clinical documentation to support the medical necessity of this request.
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