Request for Services - Prior Authorization

Standard Request - To promote more expedient turnaround times, please ensure all supporting documentation is attached. Our goal is to have a decision in less than 3 days. Requests received without medical records attached at the time of submission may take up the CMS allowed 14 days. 


To Be Completed By Person Requesting Authorization

Patient Information


Requested Services Inpatient/Observation


Requested Services Outpatient/Office/Home/Other



Skill In Place






Therapy Request







Other Services

Provider Information - Inpatient - Acute/Observation

Provider Information - Inpatient - Planned IP Admit

Provider Information - Inpatient - Post Acute

Provider Information - Inpatient - Skill In Place

Provider Information - Outpatient/Office/Home/Other

Medical Records

Note: To prevent submission errors please ensure the records have been attached for review. An error will display, and your request will not be submitted without supporting documentation attached. Also, please ensure that if you selected “Add another response” and it is no longer needed that you remove those fields prior to submission by clicking “Remove”.