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

You Are Done

When we receive your fax we will fax back an acknowledgement of the receipt.