Request For Prior Authorization Of Medication {BWC-3931}

Request for Prior Authorization of Medication Instructions · Theprescribershouldonlycompletethisform. · Pleasefaxcompletedformto866-213-6066. · Tospeakwithacustomerservicerepresentative,call877-543-6446. Injured worker information Requestdate Injuredworkername Injuredworkerdateofinjury BWCclaimnumber Prescriber information Prescriber PrescriberNPI Prescriberphone Prescriberfaxnumber Medication requested and conditions being treated (Required) Medication name 1. ICD code(s) ICD code description(s) 2. 3. 4. Non-sterilecompound Sterilecompoundpainpump Sterilecompoundother Brandnamedrug:Theinjuredworkerhasadocumented,systemicallergicreaction,whichisconsistentwithknown symptomsorclinicalfindingsofamedicationallergyandhastriedothergenericdrug(s). A copy of the signed prescription that lists all active pharmaceutical ingredients and indicates the usual and customary cost of the prescription must accompany a non-sterile compound. Post surgical medication request Dateofscheduledsurgery Justification for request (Required-attachseparatesheetifneeded.) Pleasedocumenthowthemedication(s)requestedis/arerelatedtothetreatmentoforthecontrolofsymptomsassociated withtheallowedconditionsintheclaim. Prescribersignature(required) Signaturedate BWC-3931(Rev.Sept.8,2016) MEDCO-31 American LegalNet, Inc. www.FormsWorkFlow.com