After completing the information below please fax to Empower Healthcare Solutions. Fax: 1-866-546-0484. For questions call: 1-844-865-7829.
- Medication Informed Consent Document For Behavioral or Psychiatric Conditions Under 18_Empower
- Attachment_ARRx_Synagis_PA_Form_Empower
- Statement of Medical Necessity – Adult C-II Stimulant_Empower
- ARRx_HepC_Treatment_PA_Form_Empower
- AR_Oncology_Medication_PA_Form_Empower
- Statement of Medical Necessity – Selzentry_Empower
- H.P. Acthar gel (corticotropin injection) Prior Authorization (PA) Request Form_Empower
- Statement of Medical Necessity – Xolair_Empower
- Statement of Medical Necessity – Invega Trinza_Empower
- Statement of Medical Necessity – Ingrezza and Austedo_Empower
- PA Request Form (General Request)_Empower
- Mail Order Forms
- Claim Forms – English
- Claim Forms – Spanish