Pre-authorization Request Form
*Asterisks indicate required fields.
Use this form to submit standard pre-authorization requests for:
Do NOT use this form to submit expedited requests
Expedited is defined as: when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health, or ability to regain maximum function in serious jeopardy.
Submit the appropriate request form via fax:
Instructions: This form should be filled out by the provider requesting the service or DME. Please complete all applicable fields. Prior to completing this form, please confirm the patient’s benefits, eligibility and if pre-authorization is required for the service.
To determine if pre-authorization is required, please use the electronic authorization tool on the Availity Provider Portal, review our pre-authorization lists or call the phone number on the back of the members card.
No [Note: If no, please verify with the electronic authorization tool on the Availity Provider Portal, review our pre-authorization lists or call the phone number on the back of the members card.
Expedited (STOP - do not use this form to submit expedited requests. Please submit the appropriate request form via fax).
Requested changes to existing request
Note: If anticipated length of stay is not indicated no more than two days will be assigned if approved.
Note: This request form does not serve as a notification of admission. Please reference our pre-authorization lists for instructions to notify us of an admission.