Get Performrx Universal Pharmacy Prior Authorization Form

Filling out the PerformRx Universal Pharmacy Prior Authorization Form online is an essential process for ensuring that individuals receive the medications they need. This guide provides clear, step-by-step instructions for completing the form accurately and efficiently.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access and display the form in an online editor.
2. Begin by entering the patient’s name and date of birth in the designated fields.
3. Provide the patient ID number to help in identifying the individual covered by the authorization.
4. Fill in the prescriber’s name and specialty, ensuring accurate information is entered.
5. Enter the prescriber’s phone number, as well as their address and fax number.
6. Complete the medication details by specifying the name and strength requested. If applicable, check the box for a brand medically necessary request and provide a rationale.
7. Input the anticipated length of therapy by selecting a duration from the available options: days, 3 months, 6 months, or 12 months.
8. Document the relevant diagnosis for the medication request.
9. List any preferred medications that have been tried or previous therapies, including their strength, frequency, and duration.
10. Provide a rationale or any additional information that could assist in the review of this prior authorization request.
11. Finally, add the prescriber’s signature and the date to validate the form.
12. Once all fields are filled, users may save changes, download, print, or share the completed form as needed.

Complete your PerformRx Universal Pharmacy Prior Authorization Form online today!