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Click ‘Get Form’ to open the prior authorization fax request form in the editor.
Begin by entering the date, contact person, and their phone number. Ensure you indicate whether the fax line is HIPAA secure.
Fill in the requesting provider's information, including TIN/NPI, followed by the member's details such as name, ID number, and date of birth.
Indicate if the member is pregnant or has other insurance. If applicable, provide details about other insurance coverage.
Select the type of request: Routine or Expedited/Urgent. For urgent requests, include a physician’s order stating urgency.
Complete servicing provider and facility information, including addresses and network status (in-network or out-of-network).
Provide clinical information such as diagnoses, ICD-10 codes, required CPT/HCPCS codes, and any additional visit details.
Review all entries for accuracy before submitting to ensure a smooth processing experience.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (125 Votes)

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Got questions?

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Can I request my own prior authorization?

Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered.

What items are needed to submit a prior authorization request?

You can submit a request on your own. Find the appropriate prescription drug or medical procedure authorization form for your situation.

What is a prior authorization request form?

Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesnt need prior authorization.)

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