INSTRUCTIONS: MEDIMPACT MEDICATION REQUEST FORM
Alabama physicians and providers who need to treat a public employee enrolled in the state's PEEHIP program with a Prior Authorization drug must file the document discussed in this article. This form is only to be completed when there is no suitable alternative available. This document can be obtained from the website maintained by the Retirement Systems of Alabama.
Medimpact Medication Request Form Step 1: In the first box, write the patient's name.
Medimpact Medication Request Form Step 2: In the second box, write the patient's insurance company and contract number.
Medimpact Medication Request Form Step 3: In the third box, write the patient's date of birth.
Medimpact Medication Request Form Step 4: In the fourth box, write the patient's diagnosis.
Medimpact Medication Request Form Step 5: In the fifth box, write the physician's name and specialty.
Medimpact Medication Request Form Step 6: In the sixth box, write the physician's telephone number, including area code.
Medimpact Medication Request Form Step 7: In the seventh box, write the physician's DEA number.
Medimpact Medication Request Form Step 8: In the eighth box, write the physician's fax number, including area code.
Medimpact Medication Request Form Step 9: In the ninth box, write the name of the pharmacy used by the patient.
Medimpact Medication Request Form Step 10: In the tenth box, write the pharmacy's telephone number, including the area code.
Medimpact Medication Request Form Step 11: In the eleventh box, write the name of the drug being requested.
Medimpact Medication Request Form Step 12: In the twelfth box, write the quantity per month being requested.
Medimpact Medication Request Form Step 13: In the thirteenth box, write the drug dosage.
Medimpact Medication Request Form Step 14: In the fourteenth box, write the length of treatment required.
Medimpact Medication Request Form Step 15: In the fifteenth box, write the strength of the medication.
Medimpact Medication Request Form Step 16: In the sixteenth box, write the dosage form.
Medimpact Medication Request Form Step 17: In the seventeenth box, give a detailed explanation of the reason for this medication request.
Medimpact Medication Request Form Step 18: In the eighteenth box, give a detailed list of other medications that have been tried which have failed.
Medimpact Medication Request Form Step 19: In the nineteenth box, write any other pertinent history concerning this request.
