Prior Authorization Forms/Files
| Web Forms or Files | Description |
| PA-01
Prior Authorization Form and Instructions (PDF Format) (last modified 10/10) |
The PA-01 prior authorization includes instructions for the following PA types: 01 Outpatient Surgery Performed Inpatient Hospital, 05 Rehabilitation Therapy, 09 DME Equipment & Supplies, 99 Outpatient Surgery Performed Inpatient (CPT Procedures) & all other Specialized CPT Procedures. |
| PA-02 Form (PDF Format) | When prior authorizing outpatient rehabilitation services, the PA-02 is required in conjunction with the PA-01. It should be completed and submitted with the PA-01. (Discontinued in 08/10) |
| PA-07 Form (PDF Format) | The PA-07 form is used by Home Health agencies to request extended nursing care for eligible recipients under age 21. |
| PA-14 Form (PDF Format) | The PA-14 form is designed for prior authorization of personal care services. |
| PA-15 Form (PDF Format) | The PA-15 form is designed for prior authorization of Air Ambulance services. |
| PA-16 Form and Instructions (PDF Format) | The PA-16 Form is used for prior authorization of Pediatric Day Health Care (PDHC) services. |
| Prescription Request Form for Disposable Incontinence Products (PDF Format) | Providers may submit a completed prescription request form for disposable incontinence products or a physician's prescription, along with the required documentation. Click to view the Medical Criteria for Incontinence Products |
| Prior Authorization Request for Transplant Form – TP-01 (PDF Format) | This form must be completed by the provider when requesting prior authorization for transplant. |