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Diabetes Prevention    Prior Authorization  
0           âœ†214-613-2019

pa.Request

Initial Request Form

Contact us @214-613-2019 or complete the form below to request management of a prior authorization/precertification request, and a Prime Care Health Solutions team member will reach out to you to complete your request.

Prior Authorization (PA) Management Initial Request Form

Select preferred PA Management service*

Field is required!
Field is required!

Referring Physician or Provider Information

Provide information about the provider requesting the referral.
Your Last Name
Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Middle Name
Field is required!
Field is required!
NPI Number
Field is required!
Field is required!
Specialty
Field is required!
Field is required!

Practice Contact Information

Provide information about the contact person for referral
Your First Name
Field is required!
Field is required!
Your Last Name*
Field is required!
Field is required!
Title
Field is required!
Field is required!
Your Clinic / Facility Name*
Field is required!
Field is required!
Your City*
Field is required!
Field is required!
Your Clinic / Facility Address*
Field is required!
Field is required!
State*
Field is required!
Field is required!
Your Phone number
Field is required!
Field is required!
Fax
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!

Patient Information

Your First Name
Field is required!
Field is required!
Last name
Field is required!
Field is required!
Your Middle name
Field is required!
Field is required!
Date of Birth
Field is required!
Field is required!
Gender
Field is required!
Field is required!
Your Address
Field is required!
Field is required!
City
Field is required!
Field is required!
State
Field is required!
Field is required!
Preferred Phone number
Field is required!
Field is required!
Alternate Phone number
Field is required!
Field is required!
Your E-mail Address
Field is required!
Field is required!
Patient Insurance State
Field is required!
Field is required!
Pharmacy insurance member ID number
Field is required!
Field is required!
Pharmacy BIN number
Field is required!
Field is required!
Pharmacy insurance plan or PBM name
Field is required!
Field is required!
Pharmacy insurance group number
Field is required!
Field is required!
Pharmacy PCN number
Field is required!
Field is required!
Diagnosis
Field is required!
Field is required!
Medical insurance name, primary carriers name (Insured), member ID number, group number, coverage date, effective date and customer service number
Field is required!
Field is required!
Pharmacy insurance name, primary carriers name (Insured), member ID number, BIN number, group number, coverage date, effective date and customer service number
Field is required!
Field is required!

Drug Information & Diagnosis

Provide information about the medication prescribed and diagnosis
Medication name*
Field is required!
Field is required!
Dose
Field is required!
Field is required!
ICD-10 Diagnosis
Field is required!
Field is required!
Strength
Field is required!
Field is required!
Quantity
Field is required!
Field is required!
or ICD-9 Diagnosis
Field is required!
Field is required!
Formulation
Field is required!
Field is required!
Direction (SIG) interval*
Field is required!
Field is required!
Submit

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Prime Care Health Solutions

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