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Click ‘Get Form’ to open the amerihealth authorization form in our editor.
Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the Patient ID Number, followed by the Prescriber’s details including name, specialty, phone number, address, and fax number.
In the 'Medication Name and Strength Requested' section, specify the medication along with any necessary rationale if a brand medically necessary request is indicated.
Indicate the quantity requested and anticipated length of therapy by selecting one of the options provided (e.g., days or months).
Provide details about previous therapies attempted under 'Preferred Medications tried', including strength, frequency, and duration.
Complete the 'Rationale and/or additional information' section to support your prior authorization request.
Finally, ensure that the prescriber signs and dates the form before submitting it via fax to PerformRx at 855-851-4058.

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