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Complete the online Prior Authorization (PA) request below and submit or download, print and fax the form to (888) 870-3823. If you need assistance, please call (877) 659-6101.

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I.Prescriber Information

Prescriber name & NPI:

Office contact name:

Fax:

Phone:

III.Pharmacy Information

Pharmacy Name:

Phone:

Fax:

II.Member Information

Member name:

Member ID #:

Group #:

Date of Birth:

IV.Medication History For This Diagnosis

A.Is member currently treated with this medication?

Yes For how long? No

V.Clinical Rationale For Medication:

VI.Drug Information (one medication per request form)

Drug name & strength:

Qty per Day:

Dosage form:

Diagnosis relevant to this request:

Dosing interval (sig):

Expected length of therapy:

VII.Previous treatment and outcomes

Drug name & strength:

Dates of therapy:

Reason for discontinuation:

Appropriate clinical information (including lab reports, when appropriate) to support the request on the basis of medical necessity must be submitted. Appeal Information: If you believe that this decision adversely affects your patient’s care, please contact our Customer Service line at (888) 870-3823 to request an Appeal form.

PRIOR AUTHORIZATION FORM

I.Prescriber Information

III.Pharmacy Information

II.Member Information

IV.Medication History For This Diagnosis

V.Clinical Rationale For Medication:

VI.Drug Information (one medication per request form)

VII.Previous treatment and outcomes

Copyright ©2026 - Rx Valet, LLC. Used by Permission and All Rights Reserved.

PRIOR AUTHORIZATION FORM

I.Prescriber Information

III.Pharmacy Information

II.Member Information

IV.Medication History For This Diagnosis

V.Clinical Rationale For Medication:

VI.Drug Information (one medication per request form)

VII.Previous treatment and outcomes

Copyright ©2026 - Rx Valet, LLC. Used by Permission and All Rights Reserved.

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