Healthsmart prior authorization request form: Fill out & sign online

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Click ‘Get Form’ to open the healthsmart prior authorization request form in the editor.
Begin by filling out the 'Patient and Medication Information' section. Enter the patient's name, PEIA identification number, date of birth, requested medication name, dosage, directions for use, and primary diagnosis. If applicable, include any secondary diagnoses.
Next, complete the 'Prescriber Information' section. Input the prescribing practitioner's name, address, DEA number, specialty, and contact information.
If known, provide details in the 'Pharmacy Information' section including the dispensing pharmacy's NABP number and address.
Answer all questions in Section IV regarding previous treatments and therapeutic reasons for medication requests. Be sure to provide detailed responses as needed.
Finally, ensure that the prescriber signs the form. If using a signature stamp, remember to initial it as required.

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