Prior Authorization Templates

This Form is used for requesting prior authorization for out-of-state services in Oregon.

This document is a checklist outlining the application requirements for becoming a Pharmacy Benefit Manager (PBM) in South Carolina. It contains the necessary information and steps that need to be followed to apply for PBM licensure in the state.

This document provides instructions for completing Form F-11066, which is a Prior Authorization/Oxygen Attachment form required in the state of Wisconsin. It is used to request approval for oxygen therapy services.

This Form is used for requesting prior authorization for otological medical procedures in the state of Wisconsin. It includes a physician report on the patient's condition and treatment plan.

This Form is used for providing prior authorization and attaching psychotherapy information in the state of Wisconsin.

This Form is used for submitting prior authorization and care plan attachments in the state of Wisconsin. It provides instructions on how to complete the form and what information is required.

This document is used to provide instructions for completing the Form F-11035 Prior Authorization Dental Request Form (Pa/Drf) in the state of Wisconsin.

This document is used for submitting an amendment request for prior authorization in Wisconsin. It provides instructions on how to complete the form and what information is required.

This Form is used for submitting prior authorization for blood glucose meters and test strips in Wisconsin.

This document is used for submitting supporting documents for pharmacy prior authorization in Washington state. It serves as a cover sheet to facilitate the submission process.

This document provides instructions for completing Form F-11033 Prior Authorization/Mental Health and/or Substance Abuse Evaluation Attachment (Pa/Ea) in Wisconsin. It provides guidance on how to fill out the form and includes important information about the prior authorization process for mental health and substance abuse evaluations.

This Form is used for obtaining prior authorization for home health therapy services in Wisconsin. It provides instructions for completing the Prior Authorization/Home Health Therapy/Attachment (PA/HTTA) form.

This document is used for submitting a prior authorization or care plan attachment in Wisconsin. It is required for certain healthcare services and treatments.

This Form is used for requesting prior authorization for hearing instrument and audiological services in the state of Wisconsin. It provides instructions on how to complete the form correctly.

This Form is used for submitting a prior authorization request and preferred drug list for proton pump inhibitor (PPI) capsules and tablets in the state of Wisconsin.

This Form is used for submitting a prior authorization request for health and behavior intervention services in Wisconsin. It provides instructions on how to complete the form and what information needs to be included.

This Form is used for prior authorization and chiropractic attachment in the state of Wisconsin.

This Form is used for submitting a prior authorization request or physician attachment in the state of Wisconsin. It provides instructions on how to properly complete the form and submit it for review.

This document provides instructions for completing Form F-11037, which is used for requesting prior authorization for substance abuse day treatment services in Wisconsin.

This form is used for providing instructions on how to complete Form F-11032 Prior Authorization/Substance Abuse Attachment (PA/SAA) in Wisconsin. It is a required document for obtaining prior authorization for substance abuse treatment.

This Form is used for attaching a spell of illness to a prior authorization request in Wisconsin.

This Form is used for requesting prior authorization or preferred drug list for stimulants and related agents in Wisconsin. It provides instructions on how to fill out the form and submit it to the appropriate authority.

This document provides instructions for completing Form F-11305, which is used for prior authorization and preferred drug listing for cytokine and cell adhesion molecule antagonist drugs for Crohn's Disease in Wisconsin. It outlines the necessary information and steps to be followed when requesting approval for these medications.

This Form is used for reporting a defective prior authorization form in Washington, D.C.

This Form is used for requesting prior authorization for medical services and treatments in Washington, D.C.

This Form is used for submitting a prior authorization request to Wisconsin's healthcare system. The fax cover sheet must be filled out and attached to the prior authorization form to ensure proper processing.

This Form is used for requesting prior authorization and prescription for oxygen therapy in Alabama.

This document outlines the criteria that must be met for obtaining prior authorization for the medication Evrysdi (Risdiplam) in the state of Mississippi. It specifies the requirements that must be met in order for the medication to be approved for coverage.

This form is used for requesting prior authorization for services related to early intervention for children from birth to age 3 in the state of Wisconsin.

This document is used for prior authorization and dental attachments in Wisconsin. It is a check box format form.

This Form is used for requesting prior authorization for psychotherapy services in Wisconsin. It is an attachment to the F-11031 Prior Authorization form.

This form is used for requesting prior authorization for intensive in-home treatment in Wisconsin. It is an attachment to Form F-11035. The instructions provide guidance on how to complete the form and submit it for review.

This Form is used for healthcare providers in Wisconsin to acknowledge the prior authorization request for personal care services.