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Get Uncollectible Account Authorization Form

An P.O. Box 52000, MC109 Phoenix AZ 85072-2000 You may also ask us for a coverage determination by phone at 1-866-235-5660, (TTY: 711), 24 hours a day, 7 days a week or through our website at www.silverscript.com. Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

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