Transcription of PRIOR AUTHORIZATION REQUEST FORM EOC ID: r
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PRIOR AUTHORIZATION REQUEST FORM EOC ID: r
PRIOR AUTHORIZATION REQUEST FORMEOC ID: EnvisionRx General PRIOR AUTHORIZATION - 1rrPhone: 866-250-2005rFax back to: 877-503-7231 rENVISION RX OPTIONS manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribingphysician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review Name:NAPrescriber Name:NAMember Number:Date of Birth:Group Number:Address:City, State, Zip:Member Phone:Fax:Phone:Office Contact:NPI:State Lic ID:Address:City, State, Zip:Drug Name:rExpedited/UrgentDirections:Please attach any pertinent medical history or information for this patient that may support approval.
PRIOR AUTHORIZATION REQUEST FORM EOC ID: EnvisionRx General Prior Authorization- 1r rPhone: 866-250-2005rFax back to: 877-503-7231 r ENVISION RX OPTIONS manages the pharmacy drug benefit for your patient.
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