Request Authorization Templates

This form is used for requesting authorization for medical treatment or for carriers to respond to such requests in the state of Utah.

This form is used to request system access authorization for government services in Oklahoma.

This Form is used for requesting system access authorization in the OMES (Office of Management and Enterprise Services) Elm system in Oklahoma.

This form is used for requesting prior authorization for mental health residential treatment services for individuals aged 21-64 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 requesting authorization for a long-term care facility in Alaska.

This Form is used for requesting prior authorization for Hereditary Angioedema (HAE) agents in Nevada.

This Form is used for authorizing and requesting driver instruction forms in California.

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

This document is used for submitting a security authorization request in the state of Virginia for SharePoint. It helps ensure the secure access and authorization for SharePoint users in Virginia.

This form is used for requesting prior authorization for a urine drug test in the state of Vermont. It helps ensure that the test will be covered by insurance.

This Form is used for requesting prior authorization for limited orthodontic treatment in the state of Vermont.

This form is used for requesting authorization for the medication Elapegademase-Lvlr (Revcovi) in the state of Washington.

This form is used for requesting authorization for Lutetium Lu 177 Dotate (Lutathera) treatment in Washington.

This Form is used for requesting authorization for oxygen and respiratory services in the state of Washington through the Department of Social and Health Services (DSHS).

This Form is used for requesting authorization for vision care services in the state of Washington.

This form is used for requesting authorization for Voretigeme Neparvovec-Rzyl (Luxturna) in the state of Washington.

This form is used for registering names, signatures and other identifying information of individuals looking to access the Department of Defense (DoD) systems and data.

This form is used for requesting authorization to increase inspection fees in Maryland.

This Form is used for providing instructions on how to complete Form F-01629 Prior Authorization/Behavioral Treatment Attachment (PA/BTA) in the state of Wisconsin. It is important to follow these instructions carefully in order to ensure proper submission of the form.

This Form is used for applying for a change of ownership and requesting provisional authorization in the state of Tennessee.

This form is used for requesting authorization for the Advanced Emergency Medical Technician (AEMT) Training Course in North Dakota.