Pharmacy Advantage RX


Medication Request Form

Patient Information

** Please include a copy of the front & back of all insurance cards**
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Prescription Selection:

Clinical Information:

Please submit the most recent Prescriber Notes, Lab/test results, and Prescriptions

Prescriber Information:


I certify

that the above information is true and accurate to the best of my knowledge. I authorize Pharmacy Advantage Specialty Pharmacy and its representatives to act as an agent to initiate and complete insurance prior authorizations.
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This field is for validation purposes and should be left unchanged.