Prescription and Pharmacy Benefit Management: Refer and Save

  • By Phone: 844-683-6300
  • By Fax: 877-457-1345
  • By Email: RxReferrals@SunriseMedicalSolutions.com
  • Online: complete the form below

 

Referrer Information


Claim Information

Adjuster Information

Nurse Case Manager Information


Patient Information

(last four digits only)



Prescription Authorization


Pharmacy Information


Prescriber Information


Attorney Information


Additional Information


Authorized Medications


File Upload

Prescription and other supporting referral documents may be attached electronically below.