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Green shield special authorization 2026
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- Click ‘Get Form’ to open the green shield special authorization in the editor.
- Begin with SECTION 1 – PATIENT INFORMATION. Fill in your surname, Green Shield I.D. number, employer name, first name, date of birth, telephone number, street address, city, province, and postal code. Ensure all fields are completed accurately.
- Sign and date the authorization statement at the bottom of SECTION 1. If you are under 14 years old, ensure a plan member's signature is included.
- Proceed to SECTION 2 – PHYSICIAN INFORMATION. Your physician must provide their name, signature, address, specialty, date, telephone number, province, postal code, and fax number.
- In SECTION 3 – DRUG REQUESTED FOR EVALUATION, detail the product name/strength/dose/duration of treatment. Indicate the location of administration and provide a diagnosis along with previous therapeutic history and relevant lab results.
- Complete any additional comments regarding medication or medical condition as needed.
- Finally, follow the mailing instructions in SECTION 4 to submit your request along with any required receipts.
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Can I sign my green shield special authorization request form wegovy with my mobile phone?
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