Get the free FAX TO: (888) 807-6643

Prescribing Clinician or Authorized Representative Signature Date Created 03/17 Reviewed/Revised 03/29/2017 4/13/2017 4 18 PM. Emflaza deflazacort O Medication Request Form MRF FAX TO 888 807-6643 c/o MedImpact Healthcare Systems Inc. Attn Prior Authorization Department 10181 Scripps Gateway Court San Diego CA 92131 - Phone 1-800-788-2949 Instructions This form is to be used by participating providers to obtain coverage for the drugs listed above which require prior authorization. Please...

How to fill out fax to 888 807-6643

How to fill out fax to 888 807-6643

1. Begin by obtaining a fax cover sheet, which is a document that contains important information about the fax you are sending. You can either create one yourself or use a pre-made template.
2. Write the date on the fax cover sheet to indicate when you are sending the fax.
3. Fill in your name and contact information as the sender of the fax. This includes your full name, phone number, and email address.
4. Include the recipient's information on the fax cover sheet. This should include the recipient's name, company name, phone number, and fax number (888 807-6643 in this case).
5. Write a brief and clear subject line that describes the content of the fax.
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9. Wait for a confirmation message on your fax machine indicating that the fax was successfully transmitted.
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