Download and print the most commonly requested prior authorization fax forms for procedures, physician administered drugs and pharmacy outpatient drugs.

Past medical history, provider's orders/treatment plan, IV meds, oxygen support, all pertinents lab values, all pertinent diagnostic testing, ...

This form is being used for: Check one: □ Initial Request. ☐ Continuation/Renewal Request. Reason for request (check all that apply) ...

This form should be used when prior authorization of the services is required by Blue Cross and Blue Shield of Kansas. Blue Cross and Blue Shield of Kansas.

Pre-authorization (PA) Request Form. Please refer to current pre-authorization lists to verify if service. Requires pre-authorization. Lists are located at.

General prior authorization request. Explain the clinical reason(s) for the requested medications, including an explanation for selecting these medications over ...

Prior Authorization - TDI Standard Health Care Services Prior Authorization Form ... (PDF). To view this file, you may need to install a PDF reader program ...

This form is being used for: Check One: ☐ Initial Request. ☐ Continuation/Renewal Request. Reason for Request (Check all that apply): ☐ Prior Authorization, ...

Please attach supporting documentation to facilitate your request (e.g., the history & physical, letter of medical necessity, original photographs, etc.) This ...

Forms to Download (PDF format) The forms below are all PDF documents. Simply click on the form name to open them.