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Other prior auths

The forms in this section are for provider use only.

Authorization Guidelines, Medicare (17KB PDF) - Updated 03/2006

Augmentative Communication Device - Medicaid only  (117KB PDF) - Updated 08/2007

Bilateral Reduction Mammoplasty (25KB PDF) - Updated 08/2008

Breast and Ovarian Cancer Screening by Molecular Testing (24KB PDF) - Updated 08/2007

Breast Cancer Treatment Assessment with Oncocyte DXTM (195KB PDF) - Updated 11/2007

Carotid Artery Stenting with Embolic Protection System (25KB PDF) - Updated 09/2008

Continuous Glucose Monitoring System (38KB PDF) (New 08/08)

Enteral nutrition therapy (37KB PDF) - Updated 07/2008
Enteral nutrition therapy, Medicare (30KB PDF)

Gene expression analysis PA form for breast cancer treatment assessment with Oncotype DXTM (33KB PDF) - Updated 11/2007

Home Health Care forms:

Implantable Cardioverter Defibrillator (ICD) - Patient Information & Authorization Form (140KB PDF) - Updated 08/2006

Intravenous Immunoglobulin (IVIG) PA form (27KB PDF)

Medication Management Review request form for Psychiatrists (PriorityMedicaid only; 122KB DOC)

Obesity forms:

Obstetrical (70KB PDF) - Updated 03/2008

Oxygen Therapy and Apnea Monitors (PriorityMedicaid members under 21) (21KB PDF) - Updated 10/2006

Prior Authorization, general (32KB PDF) - Updated 09/2008

Referral to Non-Participating Provider (24KB PDF) - Updated 08/2007


Last modified 11/28/08