Fillable PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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12553E (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


DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION


C
ATTENDING PHYSICIAN SECTION










• 
• 
.
PRINT
NEW REQUEST
C
ATTENDING PHYSICIAN SECTION


PRIOR MEDICATION OR TREATMENT
  


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

  
  
   (Note: Is meant by stable that there is no growth or new lesions suggesng progression.)

DIAGNOSIS
 
  






  
  
    %
  
  
  
   (Note: Is meant by stable that there is no growth or new lesions suggesng progression.)

INFORMATION RELATING TO METASTATIC RENAL CELL CARCINOMA OR METASTATIC SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK
  
   (Note: Is meant by stable that there is no growth or new lesions suggesng progression.)




Page 3 of 3















•  







D

•  


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Completed 9 February 2021

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