Provider Preference Sheet

Pharmacy Name *

Prescriber Name *

Select one, multiple, or "Select All" for all prescribers

Medical Assistant Name

Practice Name

Preferred Method for Obtaining Chart Notes

Specify method: phone, fax, or email

Responsibility for Chart Notes *

Chart Notes Contact Details

Provide contact name, phone, fax, email, and availability

PA Submission Preferred Method *

PA Submission Details

Send to plan: If PA should go directly to the insurance via verified CMM account.
Send to prescriber: If no verified CMM. Send CMM key to MD via fax/email.
CMM details (optional): Provide CMM username, password, and OTP email. Shared Gmail also allowed.