Request for Review of Coverage
Step #1: Identify yourself:
Your Name:
Phone Number:
Step #2: Provide Information on who this request is for:
Member Requesting Drug For:		(if for someone else on your account)
Member Number:		(the Health Alliance Member Number is 11 characters long)
Date of Birth:		(mm/dd/yyyy)
Step #3: Provide Information on this prescription request:
Drug Requested:
Prescribing Physician:
Prescribing Physician's Phone Number:		(Please include the area code and extension if available)
Step #4: Provide additional comments that may help with this request:
Comments: