Preferred Medical Network - One Source. Many Solutions.

Clinical Pharmacy Review Request

Phone 1-888-586-4650 or Fax 502-489-5045

Please complete this entire form.
Items in red are required

Claimant Information
Required: Please enter your name.
Social Security #: --
I.D. #:
Injury Type:
Adjuster Information
Required: Please enter your name.
Billing Address:
City: State: Zip:
Phone: --
Required: Please enter your phone number with area code.
Physician(s) completed correspondence should be mailed to:
City: State: Zip:
Clinical pharmacy review purpose or goal:

Required: Please enter your name.
Clinical pharmacy reviews are normally completed in 30 days. If you need the review completed sooner, please indicate here:
Yes, please return the review by:
Review period:
6 Months
1 Year
All History
Reviews are subject to an hourly rate. If you require estimated costs, please indicated here:
Yes, please forward estimate for this review
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: