12545E (2020-09)
Page 1 of 2
GROUP INSURANCE – HEALTH CLAIMS
PRIOR AUTHORIZATION REQUEST
Signature of physician: Date:
Signature of member:
Date:
YYYY MM DD
Yes
No
If so
PATIENT SUPPORT
PROGRAM
A
g
PRIVATE PLAN
Yes
No
PROVINCIAL PLAN
g
Yes
No
B
C
ATTENDING PHYSICIAN SECTION
CONTINUED ON THE BACK
•
•