Prior Authorization Request Form

For assistance please call (888) 989-0057

Drug Search

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

Member Information

Member 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:  
   

Member Validation

Description What you entered Eligibility File
Member Id:
Member Last Name:
Member First Name:
Member DOB:
Member Gender:
Member Address 1:
Member Address 2:
Member City:
Member State:
Member Zip Code:
Member Phone Number:

Provider Information

Remember Me:  
Provider First Name:   Provider 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 are optional. If needed you can upload and attach files to this request.

The following file extensions are allowed: ".pdf, .doc, .xls, .ppt, .txt"

Files must be 3 MB (3,000,000 bytes) or less.

Description of Attachment:    
Select a file to upload:
    
  
    

Prior Authorization Form

Drug Information

Drug Name: Therapeutic Class:
Strength: Route:
Directions:
Quantity: Days Supply: Total # of Fills:

Member Information

Member Id: First Name: Last Name:
Date of Birth: Gender: Phone Number:
Address 1: Address 2:
City: State: Zip Code:

Provider Information

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

Medical Information

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

Attachments

 
 
 
  © 2017 PerformRx, LLC. All rights reserved.
Version 7.5.1.0