Prior Authorization
(You will need the Adobe Acrobat Reader to view or print some of the items on this page.)
General Prior Authorization Forms
Request for Preservice Review
Services Requiring Prior Authorization
Forms for Specific Procedures/Items
Newborn Prior Authorization Form
Request for Authorization for Synagis
17-P Universal Authorization Form
Services Requiring Prior Authorization
Allergy Testing
Brachytherapy for Oncologic Indications
Breast Procedures
Cochlear and Auditory Brainstem Implants
Continuous Passive Motion Devices
Custom-made Knee Braces
Diagnosis of Sleep Disorders
Electrical Bone Growth Stimulator
External Insulin Infusion Pump
Functional Endoscopic Sinus Surgery
Genetic Testing for Cancer Susceptibility
Genotype Testing
Glucose Monitoring and Related Supplies
Home Oxygen Therapy
Hospital Beds Accessories
Hyperbaric Oxygen Therapy
Implantable Infusion Pumps
Implanted Spinal Cord Stimulators
Intensity Modulated Radiation Therapy
Ultraviolet Light, including Laser Therapy, for the Treatment of Skin Disorders
Lower Limb Prosthesis
Manual Wheeled Mobility Assist Device
Mastectomy for Gynecomastia
Power Wheeled Mobility Assist Device
Prefabricated and Prophylactic Knee Braces
Prophylactic Mastectomy
Prothrombin Time Self-Monitoring Devices
Single Photo Emission Computed Tomography Scans (SPECT) and Scintimammography
Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO) and Lumbar
TACE and TAE
Treatment for Urinary Incontinence and Urinary Retention
Treatment of Obstructive Sleep Apnea in Adults
Treatment of Varicose Vein (lower extremities)
Vacuum-Assisted Wound Therapy