Prior Authorization Request

Must be filled out by prescribing office. If the following information is not filled in completely, correctly, or legibly, the authorization review will be delayed. Please allow 24 business hours for processing.

Some fields are required

Patient Information
Example: 555-555-0100
Example: 555-555-0100
TrueScripts respects your privacy and will manage all Personal Health information pursuant to 45 C.F.R & 164.504(e)(2)(1) and in accordance with the approved technologies and methodologies set out by HHS in its guidance (74 Fed Reg. 42740, 42742)
Prescriber Information
Example: 555-555-0100
Example: 555-555-0100
Requested Medication Information
None
None
Tried/Failed Therapies for this Request
File Uploads

Please attach History & Physical or Clinical Notes as well as any pertinent lab results. Documentation is required for all Prior Authorizations.

If unable to attach files electronically, please call the TrueScripts Clinical Services Team at 844.257.1955.

Attach File