Fillable PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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12536E (2020-09)
Page 1 of 2




 


GROUP INSURANCE – HEALTH CLAIMS
PRIOR AUTHORIZATION REQUEST






     
  
   
 
 
               





Signature of member:


 
  
  
  
   
   
 
YYYY MM DD

No
If so
  
PATIENT SUPPORT
PROGRAM


A



g
PRIVATE PLAN
  

 
No

PROVINCIAL PLAN
g
 
No

B



C











• 
• 

PRINT
NEW REQUEST
C




  


YYYY MM DD

OUTCOME








  

  



  
  









YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Page 2 of 2

  



  






PRESCRIPTION RENEWAL
      

(before the treatment with
the requested drug)



YYYY MM DD YYYY MM DD













 
•  









•  


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Completed 9 February 2021

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