Prior Authorization Denials

Please use the form below if you would like to submit additional clinical information that justifies the medical necessity of a denied case. Requests not related to the submission of additional clinical information for a denied case will not be processed if submitted via the form below. Please note that only .PDF and .TIF file types can be supported.

Request Submission Form For Denied Cases Only

All requests require clinical information to be uploaded.

Denied Case Number *

Contact email *

Patient ID *

Patient first name *

Patient last name *

Patient Address *

Patient Date of Birth *

Member's health plan *

Reason for request? *

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Request Submission Form For Denied Cases Only All requests require clinical information to be uploaded.
Denied Case Number*	Contact email*

Patient ID*

Patient first name*	Patient last name*

Patient Address*	Patient Date of Birth*

Member's health plan*	Standard or expedited request?*

Reason for request?*

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Prior Authorization Denials

Request Submission Form For Denied Cases Only

Request Submission Form For Denied Cases Only