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Prior authorization request 10122E 2026
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- Click ‘Get Form’ to open the Prior authorization request 10122E in the editor.
- Begin by completing Section A, which requires the patient's identification. Fill in the patient's last name, first name, relationship to the member, and contact details including address and telephone numbers.
- In Section B, provide a declaration and authorization for personal information collection. Ensure you sign and date this section accurately.
- Move to Section C, where your attending physician must complete their part. This includes their details, diagnosis, and treatment information. Make sure they provide all necessary signatures.
- Review all sections for completeness. If any information is missing, it may delay processing. Once finalized, submit the form via fax or mail as instructed.
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Related links
Requests for temporary authorization should be directed to 919/541-3629 (FTS: 629-3629). Upon receiving temporary authorization, a completed Form 2800-3 must be
This manual should be read and used as a guideline for properly installing and operating the product. This manual may be changed for the system improvement,Read more