Prior Authorization
(You will need the Adobe Acrobat Reader to view or print some of the items on this page.)
General Prior Authorization Forms
Request for Preservice Review
Services Requiring Prior Authorization
Forms for Specific Procedures/Items
Newborn Prior Authorization Form
Request for Authorization for Synagis
17-P Universal Authorization Form
Universal Prior Authorization Request Form — Medications
Services Requiring Prior Authorization
Please contact the UM intake department for any questions on prior authorization at 866-902-1689 or fax 800-823-5520.