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Get and Sign Arkansas Medicaid Prior Rx Authorization Form PDF 2020-2022
Medicaid Pharmacy Unit at 800-424-7976. Client Information LAST NAME FIRST NAME MEDICAID ID NUMBER DATE OF BIRTH PHARMACY FAX NUMBER IF KNOWN Prescriber Information NPI NUMBER DEA NUMBER PHONE NUMBER FAX NUMBER MEDICATION REQUESTED PLEASE LIST DRUG AND STRENGTH Please note that if the requested medication is for an Adult CII Stimulant Hepatitis C treatment H. For questions call 1-800-424-7895. Requestor Name and Title If the following information is not complete correct or legible the PA...Show details
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