Major Medical Prior Authorization Request
Please fill out the form below.
Point of Contact
Your Name
Your Email
Your Phone
Member Details
Member Name
Member ID
Date of Birth
Plan Name
Scheduled Date of Service (DOS)
Provider Details
Provider Name
Provider NPI
Provider Tax Identification Number (TIN)
(Format: XX-XXXXXXX)
Provider Address:
Provider Phone
Street
City
State
--None--
AG
AL
AK
AB
AZ
AR
BC
BS
BC
CA
CM
CS
CH
CO
CL
CO
CT
DE
DC
DG
DF
FL
GA
GU
GT
GR
HI
HG
ID
IL
IN
IA
JA
KS
KY
LA
ME
MB
MD
MA
ME
MI
MI
MN
MS
MO
MT
MO
NA
NE
NV
NB
NL
NH
NJ
NM
NY
NC
ND
NT
NS
NL
NU
OA
OH
OK
ON
OR
PA
PE
PB
PR
QC
QE
QR
RI
SL
SK
SI
SO
SC
SD
TB
TM
TN
TX
TL
VI
UT
VE
VT
VA
WA
WV
WI
WY
YU
YT
ZA
Zip Code
Facility Details
Facility Name
Facility NPI
Facility Phone
Requested Service
Requested Service Type
--None--
Medical
Surgical
Requested Care Type
--None--
Inpatient
Outpatient
Procedure Requested
CPT Codes
(comma delimited)
ICD Codes
(comma delimited)
Estimated Billed Charges
$
Medical History / Treatment
Notes
Additional Notes for our
Prior Authorization Team
