Important! In order for fax requests to be processed as quickly as possible it is essential fax forms are sent to the correct fax number. Click here to see a list of each client's unique fax number.
In cases where you are unable to use the Cohere portal to submit your authorization, please use the form below to submit a request by fax.
If you have questions about the fax form, click here for additional details and FAQs.
Fax Form | Fax Form |
Use this link to quickly complete form digitally using Adobe on your computer. | |
If you're having trouble opening the link above, use this link to download the PDF version. | |
Please note: By submitting this fax authorization, the provider is attesting that the request is medically reasonable and appropriate. | Please note: By submitting this fax authorization, the provider is attesting that the request is medically reasonable and appropriate. |