10141E (2020-07)
Page 1 of 3
GROUP INSURANCE – HEALTH CLAIMS
PRIOR AUTHORIZATION REQUEST
AFINITOR (EVEROLIMUS)
PLEASE READ THE INSTRUCTIONS ON THE LAST PAGE OF THIS FORM.
CONTINUED ON THE BACK
Signature of physician: Date:
Signature of member:
Date:
Last name and rst name of parent/legal guardian (if applicable):
Signature of paent or parent/legal guardian (if applicable): Date:
YYYY MM DD
Yes
No
If so
PATIENT SUPPORT
PROGRAM
A
PATIENT IDENTIFICATION
g
PRIVATE PLAN
Yes Copy aached to this form.
No
PROVINCIAL PLAN
g
Yes Copy aached to this form.
No
B
DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
Coordinaon of benets: If the paent has coverage under a private insurance plan or is enrolled in a provincial drug insurance plan, please submit the request to this
plan rst. Then send us a copy of the decision noce and this form lled out by the physician, so we can analyze the request.
C
ATTENDING PHYSICIAN SECTION
• Make sure to ll out all secons so we can process the request faster. If any informaon is missing, we will send the form back to the member.
• In order to consider any diagnosis not menoned on this form, we need supporng documents (clinical pracce guidelines, clinical studies, etc.) that jusfy the drug’s
use in the given context.
