Pre-authorization Request Form

*Asterisks indicate required fields.

Use this form to submit standard pre-authorization requests for:

  • Transplants
  • Behavioral health services
  • Outpatient medical services
  • DME and professional services
  • Inpatient and outpatient surgeries
  • Skilled nursing, long term acute care, inpatient rehabilitation

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.

Expedited requests

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.

Have you verified if pre-authorization is required?  

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.

Is this request for a pre-service benefit organization determination?  
Is this request:  
Authorization Extension
Providing Additional Information
Medicare Only - Preservice Benefit Organization Determination Request

Expedited (STOP - do not use this form to submit expedited requests. Please submit the appropriate request form via fax).


Requested changes to existing request



Section I - Patient Information

Please enter patient information:
Patient last name:*
Patient first name:*
Patient middle initial:
Patient DOB:*
Patient's Regence member ID:*
ID number from member card
Patient's Regence Group Number:* Group number from member card
Patient phone:*
Include area code

Section II - Provider Information

Please enter provider information:    
Requesting Provider  
Rendering Provider  
DME Supplier  
Provider name:*
Last, First, MI
Provider specialty:*  
Tax ID number:*
NPI number:*


Phone number:*
Confidential voicemail?*
Yes No  
FAX number:*
Provider street address:*
City, State, Zip:*
Who should we contact if we require additional information?    
Contact Name:*
Contact Phone:*
Include extension if applicable
Confidential Voice Mail:*

Contact Fax:*

Section III - Pre-authorization Request
Is this request*:    
Concurrent Review    
Date of Service (if scheduled): MM/DD/YY
Please check all that apply:

Physical  address where service will occur:    
Rendering or Treating Provider:
Last, First
Street address:
Address where service will occur
Street address line 2:
City, State, Zip:

Inpatient/outpatient hospital request:    
Facility name:
Anticipated admission date (if scheduled)/Start date of treatment:
Anticipated length of stay:  

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.


DME request:      
Company name:
Tax ID number:
NPI number:
DME Street address:
Street address line 2:
City, State, Zip:
Telephone number:
Fax number:
DME - Signed copy of prescription faxed?:
Yes  No


DME - Invoice faxed?:
Yes  No



Please provide all diagnosis, CPT® or HCPCS codes and their descriptions, if available; this will help processing of your request.  
  Diagnosis code or description* CPT or HCPCS code
or description*
DME Only-
Line Item Cost
Secondary diagnosis:

Please fax the following clinical information, as appropriate for this request to 1 (855) 207-1209:
  • History & Physical
  • Treatment history
  • Laboratory/radiology/testing results
  • Current symptoms & functional impairments
  • Any other information such as chart notes that support medical necessity