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

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 as much information as possible and we will add them into the system.

3. Drug

The drug list can be searched by the drug name. If the drug is not on the list please include:

• Name of the drug.
• Dosage from (e.g. solution, gel, cream)

4. Insurance Information