Medical Prior Authorization Form
The fields marked with an asterisk (*) are required. The authorization process will be delayed if the request form is incomplete.
Please choose one.
*
Standard Request
Expedited Request
Member Information
Name
*
First Name
Last Name
ID
*
DOB
*
-
Month
-
Day
Year
Date
Gender
*
F
M
Requesting Provider Information (Primary Care or Specialist)
Name
*
First Name
Last Name
ID
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requested Service
When applicable, include supporting chart notes, diagnostic tests, and lab values.
*
Pre-auth for In Patient Admission
Out Patient Surgery
Wound Care
Chemotherapy
Pain Management
Administration of Medication
Specialty Lab
Predetermination
Durable Medical Equipment
Transplant
Out of Network
Clinical Trial
Commercial
Medicare (No Auth. required- Medicare only)
Other
Diagnosis: ICD Code and Description
Code
*
Description
*
Procedure: CPT Code/HCPCS and Description
Code
*
Description
*
Provide here with any extra information or updates to an existing authorization:
AN AUTHORIZATION DOES NOT ENSURE COVERAGE OR SUPERSEDE ANY MEMBER BENEFIT LIMITS.
Submit
Should be Empty: