Request for a Prescription Drug Prior Authorization

This form should take about ten minutes to finish. Please complete as directed. Required fields are shown with an asterisk (*).

Please contact your Health Plan if you need information in another language or format (Braille).

Enrollee Information (Step 1 of 6)

Current step number 01 Remaning Step number 02 Remaning Step number 03 Remaning Step number 04 Remaning Step number 05 Remaning Step number 06

Welcome to the Providence Request Form.

Enrollee Information

Prescriber's Information

User Information

NOTE: You must provide documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form or a written equivalent). One of these documents is required in order to process this request. If an electronic version is not available, please contact the Pharmacy Team at (503) 574-7400 or 1-877-216-3644 or fax to (503) 574-8646 or 1-800-249-7714.