Medical Referral and Prior Authorization Process Initiation
Please submit the completed "SGRX General Request for Medical Referrals and Prior Authorizations Form" along with any required documentation via the secure submission form below.
Name of Person submitting this information
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid fax number.
Format: (000) 000-0000.
HealthChoice Member Name
*
First Name
Last Name
HealthChoice Member ID
*
Please indicate if this is the initial submission of information or if you are providing additional documentation for a prior request.
*
Initial Medical Referral or Prior Authorization Submission
Providing additional documentation for a prior submission
Select the PA to complete and upload from our website:
https://connect.sgrxhealth.com/healthchoice/providers - Select the Prior Authorization Form
Upload the PA Form and Supporting Documentation Here
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Please feel free to add any additional notes or information that would be helpful for the team to be able to process this request. Please do NOT include PHI or any HIPAA covered data into this field. Any PHI or HIPAA covered data should only be submitted via the file upload submission above.
Please do not enter any PHI or HIPAA data via this field.
Please be advised that you must submit your completed request (including Prior Authorization Form & Supporting Documentation) at least 48 hours prior to the scheduled appointment.
Submission Date
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Month
-
Day
Year
Date
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