ClaimSecure uses this three-page standard form when a plan member applies for a drug its managed plans designate as requiring special authorization, mainly expensive drugs or those with potential for inappropriate use. The member covers spousal, provincial and patient assistance program coverage; the physician gives the drug, diagnosis, previous therapies, site of administration and clinical measures such as ECOG or HbA1c.
The plan member or patient completes the patient, authorization, spousal, provincial and patient assistance sections and signs; the physician completes the final page, including specialty and qualification date, and signs.
Download the current version from the source each time; forms change without notice.
Special Authorization Request – Standard Form
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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At the pharmacy, the claim returns the message 'DIN not covered; Special Authorization required'. ClaimSecure publishes a Special Authorization Drug List with approval guidelines, which members can share with their physician to check whether the criteria are met before a new drug is prescribed.
ClaimSecure's member FAQ says a change in dosage does not require a new form: the member, or the pharmacist on their behalf, calls the Customer Response Centre to report the new strength. A new special authorization form is needed at renewal when the approval was for a limited time or supply.
Depending on the drug, the physician reports ECOG status, WHO functional class, the patient's weight or HbA1c, and for Kuvan, initial and current Phe levels and the response to a 30-day Phe-restrictive diet. Further details and supporting documents can be attached to the form.