PRIOR AUTHORIZATION REQUEST FORM

  • 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.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • TrueScripts respects your privacy and will manage all Persoanal Health infomation pursuant to 45 C.F.R & 164.504(e)(2)(1) and in accoradance with the approved technologies and methodogies set out by HHS in its guidance (74 Fed Reg. 42740, 42742)
  • Prescriber Information

  • Requested Medication Information (one per form)

  • Tried/Failed Therapies for this Request (Required)

  • Drop files here or

    Attach additional page(s) for other medications tried/results, or any additional information related to this request (medical history, labs, etc.) – This will be required for Specialty Medications.

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

  • By submitting this form, you are verifying accuracy and authenticity of data submitted.