Medical Prior Authorization Request FormPDF, 254 KBLast Updated: 01/05/2026 Form

Clinical Coordination Department Medical Prior Authorization Request Form Fax: 1-800-552-8633 Phone: 1-800-452-8633 *All Medical drug requests should be faxed to the Pharmacy at 1-877-535-1391 All fields are REQUIRED. An incomplete request form will delay the authorization process 

 Standard Request



Standard Request/Quick Response ; Process quickly due to date of Service/scheduling constraints

Pre-Scheduled date of Service Auth Date needed by Definition of Expedited/Urgent; Waiting for a decision under Standard timeframe: o Could place the enrollee’s life, health, safety (of member or others) or ability to regain maximum function in serious jeopardy. o In the opinion on the practitioner, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.



Expedited Request

Physician Signature Last Name: ID # A Date of Birth Gender F  M  Requesting Provider Information (Primary Care or Specialist) Name Provider # or Tax ID NPI Telephone/Ext Fax Contact Person Service Provider or Facility (e.g., Hospital, Surgery Center, DME provider etc.) For Non-Par providers, please include: Name, Address, Tax ID, NPI, Phone /Fax Numbers & Contact Person. Name Provider # or Tax ID NPI Telephone/Ext Fax Contact Person Requested Service - Please Include supporting chart notes, Diagnostic tests & Lab Values when appropriate. Chemotherapy Specialty Lab Transplant Pain Management In Office Out of Network Radiation Therapy Durable Medical Equipment Other Clinical Trial Diagnosis: ICD Code and Description Code Code Code Description Description Description Procedure: CPT Code/HCPCS and Description *All Medical Drug codes Fax to 1-877-535-1391 Code Description Code Description Code Description Provide additional information or changes to be made to an existing authorization below: AN AUTHORIZATION DOES NOT GUARANTEE COVERAGE AND DOES NOT SUPERSEDE ANY MEMBER BENEFIT LIMITS January 1, 2026 First Name:

Pre-auth for In Patient Admission Out Patient Surgery Wound Care Member Information SIGN