Prescription Insurance Authorization

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.

If you want Dr. Goswami to write a prescription, please make an office follow-up appointment, do not fill this form.

Patient Name *
Patient Name
Frequency of medicine intake *
Phone # of Prescription Insurance
Phone # of Prescription Insurance