4D Pharmacy Management Systems improving lives with custom benefit design and revenue transparency

4D Prior Authorization

To submit a Prior Authorization form, please download the form by clicking on the link below and then print it. Complete the form and fax it to 4D Pharmacy.

Please ensure that you select the correct Prior Authorization form below

For All 4D Members

Prior Authorization Form
(.pdf 12kb Adobe Acrobat Document)

If the member is with Northwood Auto No-Fault PIP Program please us this form.

Northwood Auto Prior Authorization Form
(.pdf 12kb Adobe Acrobat Document)

Note:This form should NOT be used for a standard 4D member.

You will be able to complete and submit your Prior Authorization Form on-line shortly.