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.

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Case Number/Authorization Number *

Contact email *

Patient ID *

Patient last name *

Patient DOB *

Member's health plan *

Reason for request? *

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Request Form
Case Number/Authorization Number*	Contact email*

Patient ID*

Patient last name*	Patient DOB*

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

Reason for request?*

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Prior Authorization Denials

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Prior Authorization Denials

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