Evo First | Be Better

Prior Authorization Request

Must be filled out by prescribing office. If the following information is not filled in completely, correctly, or legibly, the authorization review will be delayed. Please allow 24 business hours for processing.

Some fields are required *

Patient Information

First Name *

Last Name *

Date of Birth *

Gender

Height in inches *

Weight in lbs. *

Allergies

Cardholder First Name

Cardholder Last Name

Prescription ID # on Card *

Prescription Group # on Card *

Patient (or Caregiver) Phone * Example: 555-555-0100

Other Phone Example: 555-555-0100

Address Line 1

Address Line 2

City

State / Province

Postal / Zip Code *

Email * Evo First respects your privacy and will manage all Personal Health information pursuant to 45 C.F.R & 164.504(e)(2)(1) and in accordance with the approved technologies and methodologies set out by HHS in its guidance (74 Fed Reg. 42740, 42742)

Prescriber Information

Prescriber Name *

Medical Facility Name *

NPI *

Prescriber Specialty

Office Contact Person *

Prescriber Phone * Example: 555-555-0100

Fax * Example: 555-555-0100

Address Line 1

Address Line 2

City

State / Province

Postal / Zip Code *

Requested Medication Information

Medication Requested *

Strength *

Quantity *

Day Supply *

Expected Length of Therapy *

ICD Code and/or Diagnosis *

If Direct Generic is Available, but Patient Requires Brand, Please Include a Letter of Medical Necessity and Check the Box Below.

Brand Name Required

Tried/Failed Therapies for this Request

Previous Medication *

Strength *

Duration (start/end date) *

Results *

Previous Medication

Strength

Duration (start/end date)

Results

Previous Medication

Strength

Duration (start/end date)

Results

Comments

File Uploads

Please attach History and Physical or Clinical Notes as well as any pertinent lab results. Documentation is required for all Prior Authorizations. If unable to attach files electronically, please call the Evo First Clinical Services Team at 844-386-0001.

Attach File

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