Request prior authorization 2026

1. Click ‘Get Form’ to open the request prior authorization document in the editor.
2. Begin by entering the 'Date of Request' at the top of the form. Ensure all required fields marked with an asterisk (*) are filled out.
3. If applicable, check the 'Urgent Request' box to indicate that this is a time-sensitive request requiring attention within 24 hours.
4. Fill in the 'Member Information' section, including First Name, Last Name, Member ID, and Date of Birth.
5. Provide 'Servicing Provider Information' by entering NPI, Tax ID, TPI, Contact Number, and Fax Number. Include details for both the servicing provider and referring provider if different.
6. In the 'Requested Service' section, select the type of service needed and fill in any additional required information such as Place of Service and Procedure Codes.
7. Complete the 'Clinical Review' section by checking relevant boxes and providing diagnosis codes as necessary.
8. Finally, ensure you sign in the designated area for the requesting physician before submitting your form for processing.

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