PRIOR AUTHORIZATION FORM
AUTHORIZATION for NON-FORMULARY MEDICATION

Download PDF Version

NOTE: Form must be submitted by authorized VA personnel

  • Form is not required if medication is on drug list/formulary.
  • Please do not include certificate, prescription, or other documentation with fax.
*only include prescriber information if prescriber override is needed
I affirm that the information given on this form is true and accurate as of this date.
This certificate may contain confidential or legally privileged information and is intended solely for the use of the individual or entity authorized to receive it. If you are not the intended recipient, disclosure, copying, distribution, or taking any action in reliance on the contents of this information is strictly prohibited and may be unlawful. Publication Number: 20110701- 10