Prior Authorization Form

A new Portal is now available for authorization requests and online status checks.
Please contact your Provider Relations Representative for enrollment or call (305) 422-9300 Option 2.

Indicate type of authorization request:

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Medicare Part Type *

Processing Type *

CMS defines expedited as those requests where applying the standard timeframe could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.

Patient Information

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Patient's Name *

First

Last

Date of Birth *

Member Policy ID Number *

Requesting Service Provider Information

Provider Name *

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Tax ID *

NPI *

Telephone *

Fax *

Group Name *

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Tax ID *

NPI *

Telephone *

Fax *

Service Provider Information

Provider Name *

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Tax ID *

NPI *

Telephone *

Fax *

Group Name *

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Tax ID *

NPI *

Telephone *

Fax *

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Provider’s Address *

City *

State *

Zip Code *

Facility Information

Facility Name *

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Tax ID *

NPI *

Telephone *

Fax *

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Facility's Address *

Street Name and Number

City *

State *

Zip Code *

Diagnosis/Complaints

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ICD10 Code (Primary DX) *

ICD10 Code *

Services Requested

Please include the Number of Units per Visit for each CPT Code if needed

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CPT Code *

Units *

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CPT Code *

Units *

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CPT Code *

Units *

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CPT Code *

Units *

Date of Service

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Start Date *

End Date *

Number of Visits Requested *

Please upload Prescription/Order and all supporting clinical documentation

Supporting clinical documentation may be requested to ascertain benefit coverage determination.Note: Prior authorization is not a guarantee of payment.

Upload File(s) *

Click or drag files to this area to upload. You can upload up to 3 files.

The file formats you can upload are .tiff, .jpg, .png, .doc, and .pdf. If attachment is over 10MB, please split the file to conform to size limit.

Captcha Security Question *

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Last Updated: 11/10/2022