Fillable PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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12525E (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





C
ATTENDING PHYSICIAN SECTION










• 
• 

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 2
DIAGNOSIS



   
  
  


  


  
  




•  


•  


















D

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