Acute physical medicine and rehab admit/extension prior authorization request
Use this form to request admission or extension for acute physical medicine and rehab services.
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Forms & publications
Notice: If you are looking for Apple Health (Medicaid) client forms and publications, please visit our Free or low-cost forms library.
Apple Health (Medicaid) prior authorizations - COVID related
Corneal cross linking prior authorization
Exondys 51 request form
Use this form to request prior authorization to prescribe Exondys 51 (eteplirsen).
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Expedited prior authorization (EPA) inventory
This guide provides an inventory of expedited prior authorization (EPA) criteria by code(s). Use this guide to determine the appropriate EPA number when submitting your claims.
General information for authorization
Providers need to complete this form to initiate the prior authorization process.
How to upload prior authorization request documents in ProviderOne
Learn how to upload prior authorization request documents into ProviderOne.
IV Iron request form
Use this form to request prior authorization for prescribing IV Iron.
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Nucala request form
Use this form to request prior authorization for prescribing Nucala (mepolizumab SC injection).
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Opdivo request form
Use this form to request prior authorization for prescribing Opdivo.
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