For Prescribers
Specialty Referral Forms
Download the specialty-specific referral form for your patient, complete all required sections, and return it to Accord by fax. Our team confirms receipt within one business day and assists with prior authorization and enrollment from there.
-
1
Download the form
Select the specialty that matches your patient's condition. Each form includes pre-populated medication options and dosing for that specialty area.
-
2
Complete all sections
Fill in patient information, prescriber details, clinical information, and the appropriate prescription. Include your NPI, license number, and prescriber signature.
-
3
Fax to Accord
Send the completed form along with required supporting documents to 386-385-7871. Call 386-456-3000 with any questions.
Specialty Forms
Download a Referral Form
Gastroenterology
Crohn's Disease, Ulcerative Colitis, IBD
Dermatology
Plaque Psoriasis, Atopic Dermatitis, Hidradenitis Suppurativa, Alopecia
Neurology
Multiple Sclerosis, CIDP, Parkinson's, Migraine, Epilepsy
Pulmonology
IPF, Pulmonary Arterial Hypertension, Cystic Fibrosis, Severe Asthma
Rheumatology
Rheumatoid Arthritis, Lupus, Psoriatic Arthritis, Spondyloarthritis
Infusions
IV Biologic Infusions, Intravenous Infusion Therapy
SC/IV Ig
Subcutaneous and Intravenous Immunoglobulin, CIDP, Immune Deficiency
Include With Your Fax
Required Supporting Documentation
Include the following documentation with your completed referral form. Incomplete submissions may delay enrollment and prior authorization.
- Insurance Card (front and back)
- History & Physical
- Patient Demographics
- Most Recent Labs
- Medication List
- Tried/Failed Therapies
Monday – Friday: 9:00 AM – 5:00 PM