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Pharmacy Prior Authorization Billing Form
Billing

Pharmacy Prior Authorization Billing Form

2 pages•17 fields•HIPAA-ready
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Pharmacy Prior Authorization Billing Form
Patient Full Name
Date of Birth
Insurance Information
Insurance carrier & policy
Medication Name and Strength
Prescribing Provider
Primary Diagnosis Code
Clinical Rationale
Previous Medications Tried
Supporting Documentation
Upload file
Submit
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This pharmacy prior authorization billing form simplifies the complex process of obtaining insurance approval for medications requiring preauthorization. Pharmacy teams can efficiently document prescription details, provide clinical justification with relevant diagnosis codes, capture prescriber attestations, and submit complete payer-specific requirements in a single organized workflow. The form supports both initial authorization requests and renewal submissions for specialty medications, biologics, and non-formulary drugs.

Ideal for retail pharmacies, specialty pharmacy operations, hospital outpatient pharmacies, and pharmacy benefit management teams, this template reduces authorization turnaround time and improves approval rates. It ensures all necessary clinical documentation, prescriber information, alternative medication trial history, and insurance-specific fields are captured upfront, minimizing back-and-forth communications with payers and expediting patient access to necessary medications while maintaining comprehensive billing compliance.

What's included

  • Patient demographics and insurance details
  • Prescription medication information with NDC code
  • Prescribing provider details and NPI
  • Primary and secondary diagnosis codes
  • Clinical justification and medical necessity
  • Alternative medication trial history
  • Duration of therapy requested
  • Supporting clinical documentation upload
  • Prescriber attestation and signature
  • Pharmacy contact information for follow-up

Who uses this template

  • Specialty Pharmacies
  • Retail Pharmacy Chains
  • Hospital Outpatient Pharmacies
  • Pharmacy Benefit Managers
  • Independent Community Pharmacies

All form fields

9 fields across 2 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Insurance InformationInsurance Info
Medication Name and StrengthText
Prescribing ProviderText
Primary Diagnosis CodeText
Clinical RationaleLong Text
Previous Medications TriedMedications
Supporting DocumentationFile Upload
8 min saved per patient98% patient satisfaction3x faster than paper

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