Prior Authorization Form Please enable JavaScript in your browser to complete this form.Indicate type of authorization request:Expedited / UrgentStandardCMS defines expedited as those requests where applying the standard timeframe could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.Patient InformationPatient's Name *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Member ID Number *Requesting Provider InformationProvider's Name *Provider's Specialty *Provider's Phone *Provider's Fax *Provider’s Address *Street Name and NumberCity *State *Zip Code *Tax IDPrimary Care Physician InformationPhysician's NameFirstLastPhysician's PhonePhysician's FaxTax IDReferral InformationReferred to Provider Name *FirstLastParNon-ParAddress *Street Name and NumberCity *State *Zip Code *Phone *Fax *DiagnosisDiagnosis DescriptionICD10 Codes *(Please enter all diagnosis for member and separate each with a comma, for example; Z00.00, Z13.1) Services RequestedCPT/HCPCS *(Please enter the codes for all services requested and separate each with a comma, for example; 93306, 72148) Additional CommentsDate of ServiceNumber of Visits Requested *Please upload Prescription/Order and all supporting clinical documentationUpload File(s) * Click or drag files to this area to upload. You can upload up to 3 files. The file formats you can upload are .tiff, .jpg, .png, .doc, and .pdf. If attachment is over 10MB, please split the file to conform to size limit.Captcha Security Question * = EmailSubmit Last Updated: 10/30/2020