Get 855 264 4964

The 855 264 4964 form is a prior authorization request necessary for obtaining certain pharmacy benefits. This guide provides detailed, step-by-step instructions to help users complete the form accurately online.

Follow the steps to ensure a smooth submission process.

1. Click 'Get Form' button to access the prior authorization request form and open it in your preferred document editor.
2. Begin filling out the patient’s information. Provide the patient name, date of birth, and member/subscriber number accurately to ensure proper identification.
3. Next, fill in the prescriber’s details, including their name, fax number, and contact information.
4. Complete the address section, including the full address, city, state, and ZIP code.
5. Indicate the primary phone number for both the patient and the prescriber to facilitate communication.
6. If applicable, include the specialty or facility name where the patient is receiving care.
7. Answer the clinical questions regarding the patient’s diagnosis, specific product requests, and any additional clinical reasons supporting the need for the request.
8. Indicate if the patient requires a greater quantity of test strips or meters than covered by the standard plan limits, and provide reasons for the request.
9. Review all provided information for accuracy and completeness. Ensure that no fields are left blank.
10. Once the form is fully completed, save your changes. You may then download, print, or share the form as needed.

Complete your prior authorization request online to ensure timely processing!