Service and device auth request forms

General authorization form

Medical prior authorization form – Updated 03/2018

Out-of-network providers: Use this to request prior authorization for medical services if there is no service-specific form

In-network providers: Use this form only if the services are not available in Auth Request (Clear Coverage™ and eviCore).

All providers: Use to request a pre-service organization determination when a Priority Health Medicare Advantage member is seeking services that may not be covered.

Service- or device-specific forms

Behavioral health forms

Authorization forms

Other behavioral health forms

Home health care services forms

Obesity services forms

Physician-supervised weight loss program forms:

Obstructive sleep apnea device and study forms

Rehab facility forms

Transplant services forms