Directory information, not recipient confirmation. Fax numbers can change and differ by department, location, form, or plan. Confirm this destination directly with DisclosedRx before sending sensitive documents. FaxFlow is not affiliated with this organization.
DisclosedRx fax number
(602) 669-1169
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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