When a drug already approved under Canada Life prior authorization needs a higher dose or more frequent dosing, the prescriber completes this request. It records when the drug was started, the starting and requested regimens, current weight and the medical rationale, backed by lab or investigation results, therapeutic drug monitoring and published evidence supporting the requested dose.
The plan member completes Part 1, Plan Member Information, and signs the consent; the prescribing physician completes Part 2, Physician's Information, and signs with their licence number.
Download the current version from the source each time; forms change without notice.
Drug Dosage Increase for a previously approved Prior Authorization Drug
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Use it when a patient's drug was previously approved under Canada Life prior authorization and the prescriber wants to increase the dose, the frequency or both. The form asks for the drug, the medical condition, the start date, the starting dose and frequency, and the new regimen requested.
The medical rationale with supporting lab results or investigative reports, therapeutic drug monitoring results where tested, and clinical literature on the effectiveness and safety of the requested dose, such as at least two Phase II or two Phase III trials or evidence-based guideline recommendations.
The plan member or patient. The form states that any costs incurred for completing it are their responsibility. It also warns that the claim assessment will be delayed if the form is incomplete or contains errors, so every question should be answered.