Appendix VI - Special authorization request form

Appendix 6 - Special Authorization Request Form

The Special Authorization Request Form is available for download in three formats. Simply print and complete the form, then fax it back to one of the numbers indicated at the top of the form.

Available Formats (Right click mouse button to save target document.)

Format	Filename
Microsoft Word 97	FormSpau.doc
Corel WordPerfect 8.0	FormSpau.wpd
Adobe Acrobat 3.0	FormSpau.pdf
	Standard Special Authorization Request Form
	Sevelamer Special Authorization Form
	Remicade Crohn's Request Form
	RA Meds Initiation of Coverage Request
	RA Meds Continuation of Coverage Request
	Methadone Special Authorization Request Form

To view or print the Adobe Acrobat PDF file will require the FREE Adobe Acrobat Reader available from Adobe at: http://www.adobe.com/prodindex/acrobat/readstep.html

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