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Get Drug Information Request Form 2017-2024

Map.com and can be accessed by clicking on the pharmacy icon) 1. Prescriber s Name (Last, First) 5. Member s Name (Last, First) 2. Prescriber s NPI 6. Member s ID 3. Prescriber s Phone 7. Member s Date of Birth (MMDDCCYY) 4. Prescriber s Fax 8. Pharmacy s Fax 9. Drug Requested 10. Strength 11. Quantity 12. Frequency of Dosing Please complete only the section(s) that pertains to the type of PA being requested. Incomplete requests will be denied. 14. Early Refill Reque.

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