Prescription Authorization Form

This form is to get your prescription authorization from your insurance company. Before filling this form, please check with your pharmacy if your prescription needs authorization. Most of the common prescriptions do not need authorization.

DO NOT FILL THIS FORM If you want Dr. Goswami to write a refill. For a refill please call our office at (973) 866-0336

Name

First Name

Last Name

Name of Medicine Requested

Frequency of intake

Once a day

Twice a day

Three times a day

Four times a day

Number of pills

Prescription Insurance Number (if this is different from Health Insurance Number)

Phone # of Prescription Insurance

(###)

###

####

Prescription Authorization Form

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