Care Prior Authorization Request Form PDF Details

Medicaid prior authorization is a process that requires health care providers to get approval from the state Medicaid program before providing certain services or drugs to their patients. This tutorial will provide an overview of how to complete a Medicaid prior authorization request form. It includes information on what services need prior authorization, what documentation is needed, and how to submit the request. Care providers who want to ensure they are providing the best possible care for their patients should be familiar with Medicaid prior authorization requirements. The form is fairly straightforward and can be easily completed with the required documentation. Providers who have any questions about the process can contact their state Medicaid office for more help.

Form NameCare Prior Authorization Request Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesmolina centennial prior authorization form, presbyterian centennial care prior authorization form, new mexico medicaid prior authorization form, blue cross blue shield centennial care prior authorization

Form Preview Example

New Mexico Medicaid Managed Care

Prior Authorization Request Form

Request Date:




United Healthcare

Outpatient FAX: (505) 213-0246

Long Term Care FAX: (505) 213-0240

Inpatient FAX: (505) 213-0181

UNM FAX: (505)


Phone: (505) 923-5757, option 4


Urgent or Expedited Initial Determination

For a Prior Authorization request to be considered “Urgent” or “Expedited,” the request must include a provider’s order stating that waiting for a decision under a standard timeframe could endanger the member’s life, health, or ability to regain maximum functionality or would cause serious pain. Provider’s signature below is an attestation that this request meets expedited/urgent criteria listed here.

Practitioner Signature:


(Required for Urgent or Expedited requests)

Member Information: Complete the information below and attach all of the clinical information pertinent to the request.

Member Name:

Other Carrier:

ID Number:


Policy/ID #:

Phone No.



Provider Information


Requesting Provider:










Servicing Provider/Facility:










Servicing Provider/Facility Address:












Tax ID/NPI #:













New/Initial Request

Ongoing Care

Previous Authorization Number:






Ambulatory/Outpatient Surgery




Home Birth



Out-of-Plan Services

Inpatient LOS:











PT/OT/ST Practitioner’s

Order Attached

Clinical Information Attached






Diagnosis(es) (ICD-9) (Required): _________



_________ _________


Procedure (Must match CPT code/s):________________________________________________________

Procedure(s) (CPT/HCPC) (Required): _________ _________ _________ _________ _________

Requested Effective Date: ___________

End Date: ___________

Number of Visits/Units: ________

Please attach all supporting clinical information to include symptoms, past medical history, diagnostic testing, conservative treatment prior to request.

Services requested. Submit all relevant clinical data to support the request for services. Failure to provide supporting documentation will delay processing and may result in a denial.

For Health Plan Use ONLY: (this would be to communicate authorization information)