Prior authorization forms

Find prior authorization request forms

These forms are for physician use only.

Please download and print the form you need, then fax it to us using the number on each form.

• Forms for drug prior authorization & medical necessity
• Other forms for prior authorization of services and surgeries

Note: If you do not find a form for the service or procedure you wish to request, log in to your Provider Center account and use the online Auth Request tool under Authorizations.


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