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 1271 downloads |
90degrees, affirmedrx, BCBSAL, BCBSFL, BCBSMN, Credence, HiLab, oreadrx, pcarx, rxsense, verusrx | August 31, 2023 | Download |
|
OreadRx Prior Authorization Request Form 1 1156 downloads |
oreadrx, rxsense | May 13, 2022 | Download |
|
RxSense Prior Authorization Request Form 1 1316 downloads |
rxsense | December 4, 2020 | Download |