Name and title of person completing form (please print)
Drug name:
Strength: Length of Therapy: Quantity Requested:
Has patient been on this drug and, if yes, for how long at this dosage?
Patient’s diagnosis requiring the use of this medication:
1. Previous history of a medical condition, allergies or other pertinent medical information that necessitates
the use of this medication:
2. Has the patient been seen by any other provider for this condition?
If so, what was the prescribers specialty?
qYes qNo
3. Previous non-prior authorized and prior authorized medications tried and failed for this condition:
Name of medication Reason for failure Date
4. Pertinent laboratory test or procedure: (if applicable)
Procedure: Findings: Date:
5. Other Information:
Physician’s Signature ______________________________________ Date ___/___/_____
Fax Request to: SGRX @ 313-264-0985
Prescribing Physician:
Name (First, Last)
Direct Phone #
Fax #
Physician specialty
Name (First, Last)
ID #
Phone # Client
Birth Date
qM qF
For ScriptGuideRX use only)
Date faxed: ___/___/_____
Date received: ___/___/_____
Date completed: ___/___/_____
Decision (all authorizations are pending valid eligibility)
click to sign
click to edit
We have received the prior authorization request for the above patient.
However, we need further information to process this request. Please
submit documentation such as labs, A1C, if applicable, and any other
information pertinent to patient’s diagnosis. Please also include any
medication tried/failed in this drug class and/or for this diagnosis; please
resubmit request with all supportive documentation.
If you have any questions feel free to contact us @ 1-855-855-7479
Please fax to: 313-264-0985
Thanks in advance
Prior Authorization Desk
Submitting the prior authorization without these requested, supportive documents will
stagnate the prior authorization process. The request will be considered incomplete and will
NOT be forwarded to clinical for review and approval until all necessary documentation is
15400 E. Jefferson Avenue • Grosse Pointe Park • MI • 48230 • 855-855-SGRX, ext 207
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