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 2669 downloads |
90degrees, affirmedrx, BCBSAL, BCBSFL, BCBSMN, Credence, Four Corners Health, HiLab, inscript, oreadrx, pcarx, rxsense, verusrx | February 26, 2025 | Download |
|
Four Corners Health General Prior Authorization Request Form 1 172 downloads |
Four Corners Health | December 31, 2024 | Download |
|
Four Corners Health GLP-1 Weight Management Prior Authorization Request Form 1 6 downloads |
Four Corners Health | April 11, 2025 | Download |