Prior Authorization Forms

Prior Authorization (approval in advance) is required for many procedures, services or supplies, including transportation.  Click here for information on obtaining an Emergency PA for medications.  Below are the forms used for Prior Authorization.

PA Forms
Form 342 Prior Review and Authorization Request Note: a completed form is required.    
Form 384 Attachment to Form 342 for Wheelchair Evaluation Request    ***Please verify that all text typed into the form is present, once the form is printed. If not, please continue text on page 7, in "Comments" section.
Form 471 Prior Authorization Change Request (NOT to be used for Pharmacy prior authorizations)  - 9/30/16
PHY-96-11 Cochlear Implant Request
Form 343 Dental PA Form
Form 386 Wheelchair Modification/Repair Form    ***This form is highly recommended for use and will be mandatory for prior authorizations submitted July 1, 2017 and after.
Form 360 Oxygen Therapy Request
Form 470 Smoking Cessation Request
Form 480 Augmentative Communication Device (ACD) Evaluation Report Form
Form 480 Instructions for ACD Evaluation Report
Web Portal Radiology (CTA Scans, CT Scans, PET Scans, MRAs, MRIs)
Web Portal Cardiology Services

BH PA Form

Prior Review and Authorization Request Form - Behavioral Health / Rehab Option - Includes Request for Additional Units Form - 9/1/17
   
Pharmacy - DME Prior Authorization Forms   
Form 369 Pharmacy Prior Authorization Request - Fillable - Effective 9/12/16
Form 369 Instructions Pharmacy Prior Authorization - External Criteria Booklet - Effective 10/2/17
Online PA Form For use by Health Professionals Only
Form 409 Pharmacy Override - Fillable
Form 409 Instructions Pharmacy Override External Criteria - Effective 5/1/15
Form 390 Miscellaneous PA Request Form
Form 389 Opioid Dependence Treatment PA Form – Effective 7/3/17
Form 391 Opioid Dependence Treatment Agreement and Patient Consent Form - Effective 7/3/17
Form 351 Synagis® PA Request for 2016-17 Season - Updated 9/1/16
Form 351 Criteria Synagis® PA Criteria for 2016-17 Season - Effective 10/1/16
Form 351 Instructions Synagis® PA Instructions Worksheet - Effective 10/1/16
Form 351 ICD-10 Worksheet Synagis® PA Worksheet - ICD-10 - Effective 10/1/15
Form 470 Smoking Cessation Prior Authorization Request Form - 7/13/14
Form 410-A Child Growth Hormone Deficiency PA Request Form- 9/10/12
Form 410-B Child Growth Hormone/Turner, Prader-Wili, or Noonan Syndrome PA Request Form- 9/10/12
Form 410-C Child Growth Failure/Mecasermin PA Request Form- 9/10/12
Form 410-D Child Growth Hormone /Chronic Renal Insufficiency PA Request Form- 9/10/12
Form 411 Adult Growth Failure PA Request Form - 1/30/08
Form 366 AIDS Wasting Request PA Request Form - 1/30/08
Form 373 DMARDS/Biological Injectables PA Request Form - 6/13/17
Form 373 Instructions Form 373 Instructions - DMARDS/Biological Injectables - Effective 7/1/16
Form 415 Hepatitis C Antiviral Agents PA Form - Updated 5/8/17
Form 415 Instructions Form 415 Instructions - Hepatitis C Antiviral Agents External Criteria - Effective 4/1/17
Form 392 Patient Consent Form for Hepatitis C Agents - 2/9/17
Criteria Antipsychotic Prior Authorization Criteria
Attachment A Antipsychotic Agents - Attachment A
Attachment B Antipsychotic Agents - Attachment B
Attachment C Antipsychotic Agents - Attachment C
Form Psychiatrist Specialty Notification for Prior Authorization of all antipsychotic drugs
Form 390 Miscellaneous PA Request Form  
Form 384 Wheelchair Seating Evaluation Form
Insulin Infusion Criteria External Ambulatory Insulin Infusion Pump