A
·
B
·
C
·
D
·
E
·
F
·
G
·
H
·
I
·
J
·
K
·
L
·
M
·
N
·
O
·
P
·
Q
·
R
·
S
·
T
·
U
·
V
·
W
·
X
·
Y
·
Z
·
·

Directory Results for Prior Authorization Request Fax Back To: 1-800-853-3844 Phone: 1-800-711-4555 5 AM 7 PM PST M-F Prior Authorization and Specialty Pharmacy Prescription Form Patient Information Patient s Name: Insurance ID: Date of Birth: Height: to Prior Authorization Request Fax Back To: 18008533844 Phone: 18007114555 5 AM 7 PM PST MF Prior Authorization and Specialty Pharmacy Prescription Form Patient Information Patients Name: Insurance ID: Date of Birth: Height: Address: Weight: Apartm