Grievances, Appeal, and/or External Review Consent for Medication
I, ____________________________________, give consent to Joyce Patient Name
Tan, a Patient Advocate from Premier Pharmacy Services and my Representative, to submit grievances, appeals, and/or external reviews for _______________________________________________________ List name of drugs
to my pharmacy benefit provider and/or insurance plan on my behalf. I am also giving Joyce Tan consent to call and check on the status of my grievance, appeal, and/or external review.
_______________________________________________________ Patient Signature
_______________________________ Date