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Prior Authorization Request Form Fax Back To: (866) 9407328 Phone: (800) 3106826 Specialty Medication Prior Authorization Cover Sheet (This cover sheet should be submitted along with a Pharmacy Prior

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How to Fill Out Fax Back to 866:

1. Start by gathering all the necessary documents and information that you need to include in the fax back form.
2. Carefully review the instructions provided on the form to ensure you understand what information needs to be filled out and any specific requirements.
3. Begin by entering your personal or business information, such as your name, address, phone number, and email address, as requested on the form.
4. If applicable, provide any additional contact information or reference numbers that may be required.
5. Next, fill out the main body of the form, which typically includes sections for specific details or requests. This may include providing account numbers, reference numbers, or specific instructions, depending on the purpose of the fax back.
6. Double-check all the information you have entered to ensure accuracy and completeness.
7. If the form requests any supporting documentation, make sure to attach or include them in the fax back.
8. Once you have completed filling out the form, review it once more to ensure all required fields are filled and the necessary documents are attached.
9. Finally, dial the fax number 866 (or any other specified number) on your fax machine or online fax service and send the completed form. Make sure to retain a copy of the fax transmission for your records.

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1. Individuals or businesses that have received a request for information or documentation via fax and are required to provide a response.
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