(onabotulinumtoxina) - Desjardins Life Insurance 2026

1. Click ‘Get Form’ to open the (onabotulinumtoxina) - Desjardins Life Insurance form in the editor.
2. Begin with Section A, 'Patient’s Identification.' Fill in the patient's last name, first name, relationship to the member, date of birth, contract number, and address details. Ensure all fields are completed accurately.
3. Proceed to Section B, 'Declaration and Authorization.' Confirm that all information is accurate and sign where indicated. This section authorizes the collection of personal information necessary for processing your claim.
4. In Section C, have your attending physician complete their identification details. This includes their name, license number, contact information, and signature.
5. Finally, in Section D, your physician will provide details about the drug subject to prior authorization. They must specify the drug name, dosage, diagnosis, and any previous treatments related to this condition.

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