Prior authorization forms are documents which are required by some medical and health care insurance providers to be completed and be filed by medical practitioners or doctors of insurance coverage holders. The form will allow the insurance provider to determine whether or not the actions, treatments, or any type of medication to be taken by the patient are covered in the patient’s insurance coverage policy.

Types of Prior Authorization Forms

Medical Treatment Prior Authorization Form – This type of prior authorization form is ideal for physicians or medical practitioners who will be verifying the patient’s insurance coverage allotted for a specific medical treatment or procedure. In the form, there are ten sections to be filled out, however, the last section is only to be completed by the insurance company. Furthermore, the first section is for indicating the type of priority of the request or referral while the second section is for the patient’s basic information, and the third and fourth sections document the details of both the ordering and rendering physicians. The fifth section of the form, on the other hand, will specify the medical procedure needed by the patient, the sixth section records the medical codes and its reasons, the seventh section enlists the services, and the last two sections are for the prescriptions and medical service history of the patient.

Medical Treatment Prior Authorization Form

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Medication Prior Authorization Form – Compared to the aforementioned medical treatment prior authorization form, this form type is only to be used by physicians who will prescribe medications for their patients. The pieces of data and information which will be collected in the form would include the physician’s name as the requestor along with the details of the recipient, the prescriber, the pharmacy where the medications will be obtained, the type of drug requested, the current medications of the patient, and the justification for the request.

Medication Prior Authorization Form

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Outpatient Prior Authorization Form – Outpatient services are services which would not require the patient to be admitted in the medical institution such as taking generic laboratory tests and medical physical examinations. In lieu of this, an outpatient prior authorization form must be used by a physician who is catering to outpatient clients or patients of outpatient services. This type of form contains four sections and an additional sheet which enlists the instructions to guide the user of the form or the physician. The billing provider and the insurance member’s or the patient’s information will be collected in the first section while the requested service to be authorized by the insurance company will be indicated in the second section of the form. Moreover, the remaining sections will state the dates of the intended services and the clinical and certification statements of the physician.

Outpatient Prior Authorization Form

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Prior Authorization Pharmacy Benefit Request Form – This form type has the same purpose to a medication prior authorization form which is to inform the insurance company about the medications or drugs to be purchased by the patient. However, compared to the aforementioned form, this document contains a medical questionnaire section which focuses on identifying the dosage needed by the patient as well as the approval of the State in the usage of the medication or drug.

Prior Authorization Pharmacy Benefit Request Form

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Essential Contents of a Prior Authorization Form

Below are essential or relevant contents which must be included in a prior authorization form and must be filled out by the insurance policyholder’s doctor or physician:

Insurance policyholder’s information

This part of the form must collect the details of the general information of the insurance policyholder such as the name that the policyholder is using in the insurance account along with the policyholder’s date of birth, policy type, and insurance membership identification number. It is important that the doctor will acquire the policyholder’s consent before signing the form to ensure that the data and information to be disclosed are permitted and authorized.

Referral justification or reason

The doctor will need to state the reason why he is using the prior authorization form either it is due to the need for the patient or policyholder to undergo transplant surgery, for an elective procedure, or for catering to the needs of the patient admitted in the emergency room.

Referring person’s information

The referring person is the doctor or the physician who is filling out the form. He must indicate his name, tax identification number, contact information, and address in this part of the form.

Admission type and needs

This is where the doctor can specify the type of medical request that he will inform to the insurance provider in order to verify the eligibility from the coverage of the policyholder or the patient. The information to document in this section of the form should include the type and date of admission as well as the contact information and fax number of the medical institution.

Prior Authorization Form Sample

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Medical Prior Authorization Form

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Prescription Drug Prior Authorization Form

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Prior Authorization and Referral Request Form

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Prior Authorization Form FAQs

Can a patient fill out a prior authorization form?

No, a prior authorization form must only be filled out by the doctor or the patient’s physician or else it will not be accepted or be validated by the insurance company and the receiving institution such as a pharmacy.

How can a prior authorization form be acquired?

A prior authorization form can be acquired in three ways. The first method is to personally head to the insurance provider’s office or company and request a form. The second method is to go to the insurance company’s website and download the form. And lastly, a prior authorization form can be acquired from other websites or sources which offers free and editable templates of the form.

Prior Authorization Request Form

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Standardized Prior Authorization Request Form

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Utilization Review Prior Authorization Form

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Prior Authorization Form Template Tips

When using prior authorization form templates, a physician or the user must check the template’s contents as well as know the rules and the requirements of the insurance company. This is to ensure that the contents of the prior authorization form template suits and meet the insurance company’s requirements and that all relevant information will be collected in the form.

Another tip to keep in mind is to retain the updated or edited prior authorization form template in order to have a reusable form in the future whenever a need arises.

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