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DisclosedRx fax number
(602) 669-1169
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Prior Authorization
Used for: Prior authorization requests and appeals for prescription medications (PA requests, denials, and related documentation)
Fax destination details
- Department
- Prior Authorization
- Purpose
- Prior authorization requests and appeals for prescription medications (PA requests, denials, and related documentation)
- Form
- Appeal Request Form — Appeal Request Form
- Address
- PO Box 35 Trexlertown, PA 18087-0035, USA
- Voice phone
- 480-561-6005
- Website
- Visit organization website
Before you send
- Confirm that this exact department handles your document or request.
- Check the organization website or call its main line for the current fax number.
- Include a cover sheet and any case, member, claim, or form reference required.
- Keep the delivery confirmation with your submission records.
Submit the Appeal Request Form only after a prior authorization denial. Include patient and prescriber information, medication details, diagnosis, and supporting documentation; mark Standard or Urgent; then fax to 602-669-1169 or email to PriorAuthorizations@disclosedrx.com.
Official form instructions are published as a downloadable file on the organization's website.
Sources and verification
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