Prior Authorization Templates

This document is used to request prior authorization for durable medical equipment (DME) specifically for children in Rhode Island. It helps ensure that children have access to necessary medical equipment.

This form is used for requesting prior authorization in Rhode Island for home modifications and/or special medical equipment/rehab equipment.

This form is used for requesting prior authorization for hospice services in the state of Utah.

This Form is used for requesting prior authorization for Applied Behavior Analysis (ABA) services in Utah.

This Form is used for requesting prior authorization for home health and personal care services in Utah.

This Form is used for requesting prior authorization for genetic testing in the state of Utah.

This Form is used for requesting prior authorization for inpatient intensive physical rehabilitation in the state of Utah.

This Form is used for requesting prior authorization for enteral formula in the state of Utah.

This document is used for determining the criteria for prior authorization of personal care services in Utah.

This document is used for obtaining prior authorization for the medication Valganciclovir Hydrochloride (Valcyte) in the state of Illinois.

This form is used for obtaining prior authorization for compound medications in the state of Ohio. It is necessary to submit this form in order to receive coverage for the cost of these medications.

This Form is used for requesting prior authorization for Omnipod insulin pumps in the state of Ohio.

This form is used for obtaining prior authorization for the medication Sublocade in the state of Ohio. It is required for patients to access this specific medication.

This Form is used for obtaining prior authorization for Synagis medication in the state of Ohio.

This form is used for obtaining prior authorization for oral medication-assisted treatment of opioid use disorder in the state of Ohio. It is required for patients seeking this type of treatment.

This form is used for requesting prior authorization for prescription medications in the state of Ohio.

This Form is used for obtaining prior authorization for Hepatitis C therapy in Mississippi.

This Form is used for requesting prior authorization for dental services in the state of Utah. It helps patients and dental providers to obtain approval from insurance companies before undergoing certain dental procedures.

This form is used for requesting prior authorization for durable medical equipment and medical supplies in Utah.

This form is used for requesting prior authorization for physical therapy and occupational therapy services in the state of Utah.

This form is used for requesting prior authorization for the medication Vyondys 53 (Golodirsen) in the state of Nevada.

This form is used for requesting prior authorization for the use of Qutenza (Capsaicin) medication in Nevada.

This form is used for requesting prior authorization for quantity limit exceptions for urine drug screens in the state of Utah.

This form is used for obtaining prior authorization for pharmaceuticals that will be administered in an outpatient hospital setting in Colorado.

This form is used for requesting changes to prior authorizations for healthcare services in the state of Colorado.

This document is for obtaining prior authorization for the medication Selzentry (Maraviroc) in the state of Florida. It is used to request approval from the insurance company before starting treatment with this medication.

This form is used for obtaining prior authorization for equipment and supplies under the DDD Tribal Health Program (THP) in Arizona.

This document is for obtaining prior authorization for Spravato, a medication used for treatment-resistant depression, in the state of Maryland.

This form is used for terminating PBS services through Kancare prior authorization in Kansas.

This Form is used for requesting prior authorization for Viltepso in Nevada.