Service & surgery request & referral forms
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The forms in this section are for provider use only.
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Miscellaneous auth and referral forms
Medical Prior Authorization form (522KB PDF) – Updated 12/2010
To request prior authorization for medical services both in and out of network, complete online and save it for your records, then print and fax it to Priority Health.
Augmentative Communication Device - Medicaid only (95KB PDF) - Updated 01/2012
Bilateral Reduction Mammoplasty (525KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Breast and Ovarian Cancer Screening by Molecular Testing (482KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Breast Cancer Treatment Assessment with Oncotype DXTM - Removed 9/17/2010
Prior authorization is no longer required when criteria in the medical policy are met. See the Genetics: Counseling, Testing, Screening Medical Policy 91540 updated 9/17/2010, page 8, for criteria.
DME / P&O prior authorization form (474KB PDF) – Updated 12/2010
Complete online and save it for your records, then print and fax it to Priority Health.
Enteral Nutrition Therapy (483KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Enteral Nutrition Therapy, Medicare (57KB PDF) - Reviewed 07/2009
General Genetic Testing (470KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Implantable Cardioverter Defibrillator (ICD) - Patient Information & Authorization Form (573KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Intravenous Immunoglobulin (IVIG) PA form (27KB PDF)
Obstetrical (581KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Oxygen Therapy and Apnea Monitors (Medicaid members under 21) (465KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Prior Authorization, general
Replaced with the Medical Prior Authorization form (522KB PDF) – Updated 12/2010
Complete online and save it for your records, then print and fax it to Priority Health.
Referral to Non-Participating Provider
Replaced with the Medical Prior Authorization form (522KB PDF) – Updated 12/2010
Complete online and save it for your records, then print and fax it to Priority Health.
Spine Referral for Neurosurgeon or Orthopedic Surgeon Evaluation (490KB PDF) - Updated 1/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Effective 2/15/2012, Medicare referral requirements will change from notification only to prior authorization.
Home health care services forms
Obesity services forms
- Bariatric surgery (502KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health. - Bariatric Surgery Evaluation Authorization (528KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health. - Medical Weight Loss Program (503KB PDF) - Updated 01/2012
Complete online and save it for your records, then print and fax it to Priority Health.
Skilled nursing and rehab facility forms
- SNF/Rehab Facility Review form (552KB PDF) - New 07/2010
Complete online and save it for your records, then print and fax it to Priority Health. - Medicare SNF/Rehab Admission Authorization form (501KB PDF) - New 05/2011
Effective 01/10/2011: Use this form to authorize admission or provide weekly review updates or a discharge summary.
Complete online and save it for your records, then print and fax it to Priority Health.
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