Initial Request Form

25%

Select preferred PA Management service*
- One-time OR as needed management of prior authorization cases
- Monthly management of 1 to 49 prior authorization cases per month
- Monthly management of 50 to 100 prior authorization cases per month
- Monthly management of over 100 prior authorization cases per month
Referring Physician or Provider Information
Provide information about the provider requesting the referral.
Last Name*
First Name*
Middle Name
NPI Number
Specialty

Practice Contact Information
Provide information about the contact person for referral
Last Name*
First Name*
Title
Clinic / Facility Name*
Clinic / Facility Address*
City*
State*
Phone number
Fax
Email address

Patient Information
Last Name*
First Name*
Middle name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Address
City
State
Preferred Phone number*
Alternate Phone number
Email address
Patient Insurance State
Pharmacy insurance plan or PBM name
Pharmacy insurance member ID number
Pharmacy insurance group number
Pharmacy BIN number
Pharmacy PCN number
Diagnosis
Medical insurance name, primary carriers name (Insured), member ID number, group number, coverage date, effective date and customer service number
Pharmacy insurance name, primary carriers name (Insured), member ID number, BIN number, group number, coverage date, effective date and customer service number

Drug Information & Diagnosis
Provide information about the medication prescribed and diagnosis
Medication name*
Strength*
Formulation
Dose*
Quantity*
Direction (SIG) interval*
ICD-10 Diagnosis
or ICD-9 Diagnosis

Prior Authorization / Pre-Certification Management Services