Medical, surgical and device authorization forms

Select your provider type in order to view applicable authorization forms.  

Contracted providers (in-network providers)

Our Auth Request tool has two portals, GuidingCare and eviCore. In-network providers should submit all authorizations through our Auth Request tool with the exception of  NICU/sick newborn authorization form, Solid organ transplant authorization form, or Bone marrow/stem cell transplant authorization form. Turnaround times vary by plan requirements, but in all cases are 14 days or less.

GuidingCare

Our Auth Request tool will use GuidingCare to process your authorization requests for:

  • Post-acute facilities
  • Behavioral health
  • Durable medical equipment (DME)
  • Inpatient
  • Outpatient
  • Home health care
  • Planned surgeries and procedures

eviCore

Our Auth Request tool will use eviCore to process your authorization requests for:

  • High-tech imaging
  • Spine surgery
  • Joint surgery
  • Lab and genetic services
Request an authorization

Non-contracted providers (out-of-network providers)

Out-of-network providers: Use these forms to request prior authorization for medical services. Always use a specific service form when available. Turnaround times vary by plan requirements, but in all cases are 14 days or less.

Hospital and other facility forms

Behavioral health authorization forms

Home health care services forms

Other medical authorization forms