Access 360 General Patient Authorization Form (PAF)

Find the right resource to assist your patients

A360 General PAF Form

Access 360 General Patient Authorization Form (PAF)

This brief form, once completed, gives Access 360 the ability to provide select services to a patient seeking assistance. Available in English and Spanish. The Access 360 General Patient Authorization Form must be signed by the patient to utilize Access 360 patient-specific support.

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Click here to fill out the form online.

Prior Authorization and Appeal Checklist

Prior Authorization and Appeal Checklists

Checklists designed to be used as a reference during the prior authorization (PA) and denial/appeal processes.

Benefit Investigation Report

Benefit Investigation Report

This piece provides an overview of the benefit investigation conducted by Access 360.

Understanding Medicare Brochure

Understanding Medicare Brochure

This brochure explains Medicare Parts A, B, C, and D, key terms commonly used, and prescription coverage within Medicare Part D. It also provides an overview of the current Medicare Coverage Gap (Donut Hole).

Denial Management Guide

Denial Management Guide

This guide provides you with resources and information to ensure you have all the tools you need to help navigate the denial of an AstraZeneca medicine.

Utilizing CMS 1500 UB 04

Utilizing CMS-1500 and UB-04 Forms

Use this guide when completing the CMS-1500 and UB-04 forms to ensure information is filled out correctly before submitting the claim.

GENERAL NONBRANDED Sample Letter of Medical Necessity

Sample Letter of Medical Necessity

This template is offered as a resource a healthcare provider could use when responding to a request from a patient’s insurance company to provide a letter of medical necessity for prescribing AstraZeneca specialty medicines.

Access360 Appeal Template

Sample Letter of Appeal

This template can be used by a healthcare provider to appeal a denial of access to an AstraZeneca medicine.

Use of these resources does not guarantee that the insurance company will provide reimbursement for AstraZeneca or MedImmune medicines, and is not intended to be a substitute for or an influence on the independent medical judgment of the healthcare provider.