GREGORY P. ZYDIAK, M.D.

BOARD CERTIFIED IN INTERNAL MEDICINE, GERIATRIC

MEDICINE AND
HOSPICE & PALLIATIVE CARE MEDICINE

Physician Consult Request for Prior Authorization Information

Research and Transmittal
Dear Pharmacy Drug Benefit Manager,
Thank-you for your physician consult request. As a covered entity you can access your
clients needed medical information directly without having to go through their physician
or clinical provider. To avoid delay and extra expense involved with having the physician
research the record I suggest you contact the patients (your clients) long-term care
facility directly for the required data.
Please help us provide better care to your clients by helping to lift some of the nonclinical administrative burdens that can (and should) be performed by administrative staff
trained for such work, instead of taking the physicians and providers away from the
bedside doing what they are trained to do. In most cases your staff can easily retrieve the
information you need much more efficiently and effectively than clinical providers can.
If you still feel you need the physician/providers expertise to assist you in performing
your managerial data gathering duties, please remit $41.00 payable to Gregory P. Zydiak,
MD to help defray the costs involved with your request.
Please fill out the form below so we can either, 1) prepare your request in a timely
manner or 2) know that you have taken responsibility for your job and let us get on with
ours.
Name of Pharmacy Drug Benefit Management Entity
______________________________________________________Date______________
_______ We will need the expertise of a physician or clinical provider to perform our
managerial duties and have enclosed $41.00 check payable to
Gregory P. Zydiak, MD. Please send to address below. PA will be completed
upon receipt of funds.
_______We will use our own resources and staff to perform our managerial duties and
will not need the expertise of a physician or clinical provider to gather the
needed data. (Please fax to 314-968-4369)
We look forward to partnering with you to help provide our patients (your clients) with
exceptional yet cost effective care.
Gregory P. Zydiak, MD
415 OAK TREE DRIVE - WEBSTER GROVES - MISSOURI 63119
PHONE 314-351-6189