Pharmacy General Medical Authorization eForm Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form. Member ID* Member DOB* MM slash DD slash YYYY Member Name* First Last Error Message Member Phone Number*Section 1: Provider InformationProvider Name* First MI Last Specialty NPI (Type I)* Contact Name* First Last Phone*FaxEmail* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Section 2: Servicing Facility InformationServicing Facility Name* NPI(Type II)* Tax ID* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Extension Different mailing address Is Mailing Address different than above? Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Section 3: Clinical InformationRequested J-Code* Example J code: A1234Drug name and strength Units requested Please enter a number from 0 to 9999999999.Requested CPT code(s)(Click + or - at the right to add up to 5 CPT Codes) Example CPT code: 12345 Dates of Service* MM slash DD slash YYYY Request type*Request type *InitialContinuationDirections*ICD 10 Code(s)*(Click + or - at the right to add up to 5 Diagnoses) Example ICD 10 Diag Code: Z87.890 Section 4: AttachmentsClinical notes / labs / documentation* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB. Upload only PDF and Word filesRequest Method*Request Method *StandardExpeditedSignature*Signature Date* MM slash DD slash YYYY CommentsCAPTCHA