Prior authorization request form: Fill out & sign online

Here's how it works

01. Edit your prior authorization request form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send indiana prior authorization via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out health authorization request with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the health authorization request in the editor.
Begin by filling out the Patient Information section. Enter the IHCP Member ID, Date of Birth, and Patient Name accurately.
Next, provide Requesting Provider Information. Include the Requesting Provider NPI/Provider ID, Taxonomy, and contact details.
In the Rendering Provider Information section, input the Rendering Provider NPI/Provider ID and their contact information.
Complete the Medical Diagnosis fields using ICD Diagnostic Codes for Dx1, Dx2, and Dx3 as required.
Select the appropriate assignment category from options like DME, Inpatient, or Outpatient.
Fill in Dates of Service and any additional notes necessary for your request.
Finally, ensure you include a signature of a qualified practitioner along with the date before submitting your request.

Start using our platform today to streamline your health authorization requests for free!

See more health authorization request versions

We've got more versions of the health authorization request form. Select the right health authorization request version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (217 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Contact us

What is an authorization request in healthcare?

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.)

How long does it take for an authorization to get approved?

Prior authorization timelines vary docHubly depending on the medications complexity, the type of insurance, and the submission method. While standard approvals typically take 24-72 hours, complex cases can extend to 30+ days.

How to obtain preauthorization for a patient?

The Prior Authorization Process Flow The healthcare provider must check a health plans policy or prescription to see if Prior Authorization is needed for the prescribed treatment. The healthcare professional must sign a Prior Authorization request form to verify the medical necessity claim.

What is a health authorization form?

A HIPAA authorization is a detailed document in which specific uses and disclosures of protected health are explained in full. By signing the authorization, an individual is giving consent to have their health information used or disclosed for the reasons stated on the authorization.

indiana prior authorization form pdf

Health authorization request form Health authorization request pdf Highmark Prior Authorization Form pdf Highmark Wholecare prior authorization Form Highmark prior authorization phone number UPMC prior Authorization form Highmark bcbs pennsylvania prior authorization lookup tool Highmark Wholecare prior authorization list