Prior Authorization Request Form

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  • Drug Information

    Drug Search

    Enter values for one or more of the below drug search fields.
    Label Name:
    NDC:  
    GPI 14:
    DDID:
        

  • Member Information

    Member Information

    Cardholder ID:
    First Name: Last Name:
    Date of Birth:
    RadDatePicker
    RadDatePicker
    Open the calendar popup.
     
    Gender:
    Phone Number:
    Address 1: Address 2:
    City: State: Zip Code:
       

  • Provider Information

    Provider Information

    Remember Me:  
    First Name: Last Name: NPI:  
    Specialty:
    Practice Name:
    Address 1: Address 2:
    City: State: Zip Code:
    Contact Person: Office Phone: Office Fax:

    Medical Information

    Height:  ft  in Weight:  kgs  
    Drug Allergies: ICD Code:
    Diagnosis:
    Rationale for Request:  
       


  • Attachments

    Attachments

    Attachments are optional. If needed you can upload and attach files to this request.
    The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .ppt, .txt"
    Files must be 3 MB (3,000,000 bytes) or less.

    Description of Attachment:  
    Select a file to upload:
        
       To attach a document you must click the 'Attach' button.
      
        

  • Submit for Processing
     
 
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