PA3 Renewal form

Prior Authorization Level 3
Renewal Form
**SENSITIVE BUT UNCLASSIFIED**
This form is to be completed and signed by the CCE/NPN Medical Director and should only be used for prescriptions
renewed through the World Trade Center Health Program (WTCHP).
The CCE/NPN should upload this completed form into VitalPoint and inform the PBM and the WTCHP of this request
via the SAMS messaging system. Not to be used for formulary additions.
Member Information
Request Date:

Provider/Requestor Information

Survivor
Responder

Requestor Name:

Requestor Credentials:
Requestor Phone:

Member Name:

Date of Birth:

Requestor Fax:

Member 911#:

CCE/NPN:

Request Email:

Relevant Certified Condition(s) and ICD Code:

Request Urgency:

Routine

Urgent

Urgency Rationale:
Prescribing Information
Brand Name:

Compound medication?

Generic Name:

Prescribed strength:

Drug Class:

Prescribed directions:

Yes

No

Dosage form/route of administration:
When did the member start this medication?
What is the expected duration of treatment with this drug? (Maintenance, 14 day course, etc)
Is the member using other medications concurrently to treat this condition?

Yes

No

If yes, please fill out table below.

Medication

Dosage

Is there lab monitoring required for this medication?

Yes

Dosing Schedule

Length of Therapy

No

If yes, please provide the results of the most recent lab:
Do these results show improvement in the member’s condition and/or support continued use of the medication?

Yes

No

Please explain:
Has the member’s condition improved since starting this medication?

Yes

No

If yes, please provide a description of the member’s symptoms including frequency of occurrences of emergency room visits or hospitalizations?
Provide any additional information regarding the member’s response to the requested medication.

TO BE FILLED OUT BY
WTC HEALTH PROGRAM
Decision:
Decision Comments:

By signing below, I certify that the above information is correct and accurate to the best of my knowledge.
__________________________________________
WTCHP (NIOSH) Signature

_______________________________
Date

__________________________________________
CCE/NPN Medical Director (or Designee) Signature

_______________________________
Date

**SENSITIVE BUT UNCLASSIFIED**