Prior Authorization Request Form


(4.8 / 5) 90 votes
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Get your Prior Authorization Request Form in 3 easy steps

  • 01 Fill and edit template
  • 02 Sign it online
  • 03 Export or print immediately

What Is the Prior Authorization Form?

Prior Authorization Form is a confidential document that is intended to collect information about a member and a provider of medication along with medication data (including name, strength, dosage, and direction of use), and comprehensive clinical information. The form is requested by health insurance organizations to permit patients to receive medication legally. Applicants must have an Insurance ID to fill the form.

Prior Authorization Request Form Screenshot

What I need the prior authorization form for?

Prior Authorization Form:

  • Is needed to define if a particular health insurance organization can cover expenses for a prescribed procedure, medication, or other related services. 
  • Is intended to reduce patient’s health care expenditures;
  • Is not obligatory to apply for, but most health insurance companies require it.

Patients must submit the form before the start of treatment that they want to be reimbursed by their insurance company.

Filling out Prior Authorization Form

To fill out a Prior Authorization Form properly, you have to provide a valid Insurance ID number, passport information, and a phone number. The next step is to enter the provider’s info, including the name, NPI number, and contact information. Then you have to provide information upon your prescription to define medication or another form of treatment.

The 4th field requires other anamnesis information, such as a confirmed diagnosis, therapy duration, and other details. Your doctor can also ask you to add a comment that defines your health state to add value to the form. The final step is to send the filled form to the health insurance organization that provides you with the insurance service.

Prior Authorization Request Form Template Screenshot

Organizations that work with prior authorization form

  • USA Hospitals;
  • USA Insurance companies.
Fillable online Prior Authorization Request Form
(4.8 / 5) 90 votes
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