Fillable PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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12554E (2020-09)
Page 1 of 3




 


GROUP INSURANCE – HEALTH CLAIMS
PRIOR AUTHORIZATION REQUEST






PLEASE READ THE INSTRUCTIONS ON THE LAST PAGE OF THIS FORM.
     
  
   
 
Signature of physician: Date:
               





Signature of member:
Date:

 
  
  
  
   
   
 
YYYY MM DD
Yes
No
If so
  
PATIENT SUPPORT
PROGRAM


A
PATIENT IDENTIFICATION


g
PRIVATE PLAN
Yes  

 
No

PROVINCIAL PLAN
g
Yes 
No

B
DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION


C
ATTENDING PHYSICIAN SECTION









CONTINUED ON THE BACK
• 
• 
.
PRINT
NEW REQUEST
C
ATTENDING PHYSICIAN SECTION


PRIOR MEDICATION OR TREATMENT
  


PRESCRIPTION RENEWAL

• 
• 
YYYY MM DD
MEDICATION OR TREATMENT NAME
OUTCOME








  

  



  
  
TREATMENT PERIOD








YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Page 2 of 3
INFORMATION RELATING TO CHRONIC LYMPHOCYTIC LEUKEMIA
  

   

 
   
  
DIAGNOSIS
  

INFORMATION RELATING TO MANTLE CELL LYMPHOMA
  

INFORMATION RELATING TO FOLLICULAR LYMPHOMA
  
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














•  







D

•  


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Completed 9 February 2021

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