1. Fax Example

To the right is an example of one of our fax requests for information. 

• If a PA is no longer needed or you need to cancel the request you can select the option and fax it back to us.

2. Fax Us Records or Questionnaire

Fax us either the:

• Last office visit or other appropriate documentation.
• Answer the questionnaire (see right for example)

Not all medication will have a questionnaire yet, in which case please fax us the medical records.

Our fax is: 888-286-3058

3. Submit

When you are done with the questions:

1. Select "Save and Submit"
2. Select "Submit"

You Are Done

Once the questions have been submitted they will become grey.