To submit a prior authorization online, please click the button below to use the web form.
PDF forms are available below to submit a prior authorization through fax.
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
FDA Medwatch Form 1 2285 downloads |
90degrees, affirmedrx, BCBSAL, BCBSFL, BCBSMN, Credence, Four Corners Health, HiLab, oreadrx, pcarx, rxsense, scriptwellrx, verusrx | December 31, 2024 | Download |
|
Four Corners Health General Prior Authorization Request Form 1 5 downloads |
Four Corners Health | December 31, 2024 | Download |
|
Four Corners Health GLP-1 Weight Management Prior Authorization Request Form 1 4 downloads |
Four Corners Health | December 27, 2024 | Download |