Prior Authorization Form

Indicate type of authorization request:

Expedited / Urgent
Standard

CMS 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 Information

Patient's Name *

First

Last

Date of Birth *//

Member ID Number *

Requesting Provider Information

Provider's Name *

Provider's Specialty *

Provider's Phone *

Provider's Fax *

Provider’s Address *

Street Name and Number

City *

State *

Zip Code *

Tax ID

Primary Care Physician Information

Physician's Name

First

Last

Physician's Phone

Physician's Fax

Tax ID

Referral Information

Referred to Provider Name *

First

Last

Par
Non-Par

Address *

Street Name and Number

City *

State *

Zip Code *

Phone *

Fax *

Diagnosis

Diagnosis Description

ICD10 Codes *

(Please enter all diagnosis for member and separate each with a comma, for example; Z00.00, Z13.1)

Services Requested

CPT/HCPCS *

(Please enter the codes for all services requested and separate each with a comma, for example; 93306, 72148)

Additional Comments

Date of Service

Number of Visits Requested *

Please upload Prescription/Order and all supporting clinical documentation

Upload 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 *

Last Updated: 10/30/2020