Appeal Form | Evo First

APPEAL FORM

Complete all fields. Please be specific and detailed. Provide any new or additional information to support the appeal such as medication history, diagnostic workup, lab results, chart notes, etc.

Appeal Form

Medication Requested

Member's First Name

Member's Last Name

Date of Birth

Phone #

Prescription Group # on Card Input should be in format 9999XXXX

Member ID #

Explain why this medication is medically necessary:

Provider Information

Provider Name

NPI #

Phone #

Fax #

Provider Address

City

State

Zip Code

Person Requesting Appeal

Name

Signature

Upload Documents

Submitting Your Appeal...