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English (US)
Spanish (Latin America)
Prior Authorization Request Form
Help us help you! This form is required for all prior authorization requests to ensure the quickest turnaround time. The office is unable to submit requests without accurate and up-to-date information. Thank you!
Patient Name Listed on Insurance Card
*
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Date
Medication
*
Dose
*
Quantity per 30 days
*
Medications previously tried and why it was discontinued
*
Prescription Insurance Provider
May be separate from medical insurance provider
RxBIN
*
Call your pharmacy if you are not sure
RxPCN
*
Call your pharmacy if you are not sure
RxGroup
*
Call your pharmacy if you are not sure
Member ID
*
May be separate from medical insurance member ID
Front of Prescription Insurance Card
Back of Prescription Insurance Card
Front of Prescription Insurance Card
Browse Files
Drag and drop files here
Choose a file
If unable to take a current picture, please submit it as a file
Cancel
of
Back of Prescription Insurance Card
Browse Files
Drag and drop files here
Choose a file
If unable to take a current picture, please submit it as a file
Cancel
of
Patient's Address Listed with Insurance
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is your provider
Please Select
Dr. Banov
Dr. Falcao
Dr. Morris
Dr. Kotwicki
Marla Fleming
Namita Patel
Rebecca White
Brittany Toliver
Lea Morelle
Erika Kang
Kim Lanier
Cell Phone Number
*To text when approved*
If you are unable to submit copies of your prescription insurance card, please email them to info@psychatlanta.com
Submit
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