Preferred Medical Network - One Source. Many Solutions.

Prescription Bill Review Form

Phone 1-888-586-4650 or Fax 502-489-5045
Email rx@preferredmedical.net

Please complete this entire form for bill review.
Items in red are required

Adjuster Information: 
Name:   
Phone:   
Email:   
Requested Action:    Please set up in pharmaceutical program
    30 Days 60 Days 90 Days 6 Months 1 Year
Do not set up for future prescriptions
Previously set up in pharmaceutical program
Claimant Information: 
Claimant:   
Employer:   
Date of Injury:   
Date of Birth:   
Claim #:   
SSN #:   
Address:   
Phone:   
The following must be completed:
 
Is the medication(s) listed on the attached bill approved?
Yes  No  One time only 
Any additions
 
Is the physician listed on the attached bill approved?
Yes  No  One time only
Any additions
 
File Attachment:
 
Attach a digital copy of any documentation to this form. Microsoft Word, Plain Text, PDFs, JPEGs, TIFFs and GIFs accepted.
File size must be 5 MB or smaller.

 
Please choose a file: