Prior Authorization Secure

Print, Fill Out, and Fax

Certain medications require prior authorization before being filled by the pharmacy.

Simply click on the link below to open or save it.  Print out the form and fill in the information.  Fax the Prior Authorization form, copy of the prescription, most recent physician office notes, and a letter of medical necessity to our secure fax line (812-254-7426).  We’ll take care of the rest.

Click here to download the Prior Authorization Secure