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P.O. Box 327, MS 432
Seattle, WA 98111-0327
 

Pharmacy Services Prior Authorization Form

Patient Name: ID Number:
Date of Birth:
Prescriber's Name: Office Contact:
Fax Number:
Prescriber's Address:
Prescriber's Signature: Date: Phone Number: Ext.:
Requested medication, strength and dosing schedule
Name of the Drug:
ICD Code: Strength:
Diagnosis:
Quantity/Month: Dosing Schedule:
Medications Tried
  Name Strength Dosing Schedule Therapy Duration Dates tried Reason therapy stopped
1
2
3
4
5
Additional pertinent information

Please fax this back to Pharmacy Services 
Fax Number
1-888-260-9836
 
Phone Number
1-888-261-1756