Physical Health Prior Authorization Request Form

This PDF provides a fillable Physical Health Prior Authorization Request Form intended for healthcare providers. It outlines the necessary information needed to request authorization for various medical services, including inpatient and outpatient procedures. Providers are advised to submit requests in advance and ensure that clinical notes are attached to avoid delays. The form emphasizes the importance of verifying patient eligibility to secure payment for services. Additionally, it includes a confidentiality notice to protect sensitive information.