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Recent Requests

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New Prior Auth

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Add clinical notes or labs

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Upload patient chart or clinical notes

PDF, JPG, or PNG — we'll extract the details

— or fill in manually below —

1

Patient Information

Patient Full Legal Name *

Date of Birth *

Gender

Insurance Member ID *

Insurance Group Number

Subscriber is same as patient

2

Insurance / Payer

Payer *

Plan Name

PA Fax Number

PA Portal Name

3

Prescribing Provider

Physician Full Name *

Prescriber NPI *

Practice Name

Practice Phone

Practice Address

Practice Fax

DEA Number

Required for controlled substances only

4

Medication Requested

Drug Name + Brand *

Strength

Dosage/Frequency

Route

Duration Requested

Initial or Renewal?

Initial Renewal

Appeal of denied PA?

No Yes

5

Diagnosis

Primary Diagnosis *

Primary ICD-10 Code *

Secondary Diagnoses

CPT Code

Clinical Values

6

Step Therapy History

Contraindications

7

File Uploads

Clinical Notes (optional if chart uploaded above) Choose file

Denial Letter (required for appeals) Choose file

Lab Results (optional) Choose file

8

Urgency + Notes

Priority

Standard STAT — 24 hours

Additional Notes

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Request ID	Patient	Drug	Payer	Status	Next Action	Updated

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Recent Requests

Request Status

Recent Updates

Quick Actions

New Prior Auth

Upload Documents

Check Status

Invite Team

SLA & Performance

Upcoming & Pending

Patient Information

Insurance / Payer

Prescribing Provider

Medication Requested

Diagnosis

Step Therapy History

File Uploads

Urgency + Notes

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Security Questions

Support

My Requests

Patients

Documents

Messages & Activity

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