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.
Fax our Request form (PDF) to:
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 the provider website for instructions to notify us of an admission.
If you prefer, you may print and fax a completed Pre-authorization Request Form (PDF) with supporting documentation to 1 (855) 232-0090.