Manulife drug prior authorization form: Fill out and sign online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your plan member and patient information. Fill in the plan contract number, your name, address, phone number, date of birth, gender, and email address if applicable.
3. Next, provide details about the provincial plans. Indicate whether you have applied for coverage under a provincial program and if you have been approved.
4. Specify the drug strength and dosage along with where the treatment will be administered (e.g., home, MD office).
5. Select the diagnosis for which the drug has been prescribed and provide previous therapies attempted. Include outcomes for each therapy.
6. Complete the prescribing physician's section with their name, address, and signature to authorize the request.
7. Finally, sign as the plan member certifying that all information is accurate before submitting your form via mail or fax.

Start filling out your Manulife drug prior authorization form online today for free!