Fax: 1-877-378-4727-2026

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The document is a Prior Approval Request form for the prescription drug SPINRAZA, intended for patients diagnosed with Spinal Muscular Atrophy (SMA). It requires completion by both the cardholder and the prescribing physician, detailing patient information, diagnosis confirmation, treatment history, and necessary medical tests. The completed form must be submitted to a specified address or fax number for processing. Additionally, it outlines alternative methods for submitting prior authorization requests electronically or via phone.

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Click ‘Get Form’ to open the Fax: 1-877-378-4727 document in the editor.
Begin by filling out the Cardholder and Patient Information section. Enter the cardholder's name, patient’s name, address, date of birth, and sex. Ensure all fields are completed accurately.
Proceed to the Physician Completes section. The physician must answer questions regarding the patient's diagnosis and treatment history. Make sure to check 'Yes' or 'No' where applicable and provide any necessary details.
Complete the prescriber certification at the bottom of the form. The physician should print their name, provide contact information, and sign the document to validate it.
Once all sections are filled out correctly, save your changes. You can then fax the completed form to 1-877-378-4727 directly from our platform for convenience.

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2017	4 Satisfied (24 Votes)

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