Eligibility Verification Portal EVP Access Form 2026

1. Click ‘Get Form’ to open the Eligibility Verification Portal EVP Access Form in our platform.
2. Begin by selecting whether this form is a request for new access or an update to existing information. This helps streamline your submission process.
3. In SECTION 1, provide your Pharmacy Provider Information. Fill in the required NPI Number, Legal Name, Provider DBA Name, Business Address, City, State, ZIP, Telephone, Fax, and Email.
4. Move to SECTION 2 and enter the EVP Administrator Information. Include the Contact Name, Contact Title, Business Address, City, State, ZIP, Telephone, Fax, and Email.
5. In SECTION 3, list any Additional EVP Users by entering their First Name, Last Name, and Phone Number if it differs from above.
6. Once all sections are completed accurately, save your changes and choose to send the form via fax or email as instructed at the bottom of the document.

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