PerformRx

Welcome to the PerformPA Web Submission Form

Using our online web submission form providers will be able to:

  • Electronically submit all relevant member information.
  • Attach member specific documents such as labs, chart notes, consults etc. (recognized formats .pdf, .doc, .xls, .ppt, .txt)
  • Save unique provider information in order to expedite future web submissions.
  • Print summary page for easy referencing.

Please provide as much relevant medication information as possible to increase the accuracy of your form submission.
Note: Incomplete forms will not be processed.

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Version 7.18.0.0
Last update 11/11/2022 4:41:10 PM