What is Needed?

For a prior authorization request we need four pieces of information in order to complete the request.

1. Patient Demographics

At a minimum we need the following information:

• First and last name
• Date of birth
• Full address (Street, City, State, Zip)

The phone number is not required, but can be very helpful.

2. Prescriber Information

We have a drop down list of prescribers that we have previously completed requests for. The prescribers can be searched by:

• Name
• NPI Number

If the prescriber is not on the list please include