Standard Prior Authorization Request Form
Section I — Please fax your request to 866-756-9733.
Date and Time Submitted:
Section II — General Information
Section III — Patient Information
Section IV — Provider Information
Section V — Services Requested (with CPT, CDT, or HCPCS Code) and Supporting Diagnoses (with ICD-10 Code)
Section VI — Clinical Documentation
Please provide a brief explanation of medical necessity for service(s) and attach supporting clinical documentation with this request.
Please provide contact information, in case we need more information
Preferred meathod of contact is:
Section VII — Reason for Denial or Partial Denial