10146E (2020-07)
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GROUP INSURANCE – HEALTH CLAIMS
PRIOR AUTHORIZATION REQUEST
PLEASE READ THE INSTRUCTIONS ON THE BACK OF THIS FORM.
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
CONTINUED ON THE BACK
• 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.
SATIVEX (DELTA-9 TETRAHYDROCANNABINOL/C)
