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Desjardins prior authorization form

Prior authorization request 10122E 2026

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4.8 out of 5

36 votes

The document is a prior authorization request form for Botox treatment under Desjardins Insurance's group health claims. It requires patient identification, details about the patient's condition, and physician information to assess eligibility for reimbursement. The form emphasizes the need for complete information to avoid delays and outlines the process for submitting claims, including the necessity of prior approval and potential follow-up requests.

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Click ‘Get Form’ to open the Prior authorization request 10122E in the editor.
Begin by completing Section A, which requires the patient's identification. Fill in the patient's last name, first name, relationship to the member, and contact details including address and telephone numbers.
In Section B, provide a declaration and authorization for personal information collection. Ensure you sign and date this section accurately.
Move to Section C, where your attending physician must complete their part. This includes their details, diagnosis, and treatment information. Make sure they provide all necessary signatures.
Review all sections for completeness. If any information is missing, it may delay processing. Once finalized, submit the form via fax or mail as instructed.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (36 Votes)
2014	4.2 Satisfied (74 Votes)

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desjardins authorization form

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