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.