Performrx prior authorization form pdf 2026

1. Click ‘Get Form’ to open the performrx prior authorization form in the editor.
2. Begin by entering the patient's information, including their name, date of birth, and AmeriHealth Caritas ID number. This ensures that the request is accurately linked to the correct patient.
3. Next, fill in the physician's details such as name, specialty, NPI number, phone, fax, and address. This information is crucial for communication regarding the authorization request.
4. Indicate the drug requested by checking the appropriate box for Suboxone® or Subutex®, along with specifying the dosage and anticipated length of therapy.
5. Complete the diagnosis and code section. Select whether this is an initial or renewal request based on your patient's treatment history.
6. Carefully check all applicable criteria listed on the form. If any boxes are unchecked, provide explanations on the second page as required.
7. Finally, ensure that all sections are filled out completely before signing and dating the form. Submit it via fax or mail as indicated at the bottom of the document.

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