Superior Prior Authorization Form PDF Details

If you are a healthcare provider, then you know that prior authorization is an important part of the process for getting approvals for treatments and procedures. In order to make the process as smooth as possible, it is important to have a quality prior authorization form. The Superior Prior Authorization Form is designed specifically for this purpose, and it can help you get approvals quickly and easily. This form is available free of charge on our website, and we encourage you to download it today.

We've collected some statistical information regarding the superior prior authorization form. You'll have the assumed time it might require you to fill in the form as well as additional details.

Form NameSuperior Prior Authorization Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namessuperior medicaid pa forms, superior medicaid prior authorization form, superior prior auth form, superior health plan pa request form

Form Preview Example


(*Do Not Use This Form for Biopharmaceutical Products*)

FAX this completed form to 866-399-0929

OR Mail requests to: US Script PA Dept., 2425 West Shaw Avenue, Fresno, CA 93711

Call 800-460-8988 to request a 72-hour supply of medication.

I. Provider Information


II. Member Information




Prescriber name (print):


Member name:




Prescriber Specialty:


Identification number:






Date of Birth:




Office Contact Name:


Medication allergies:




III.Drug Information (One drug request per form)

Drug name and strength:

Dosage form:

Dosage interval (sig):

Qty per Day:

Diagnosis relevant to THIS request:

Expected length of therapy:

Medication History for this Diagnosis

A.Is member currently treated on this medication?

yes; How Long?_______________ [go to item B]

no [skip items B & C; go to item D]

B.Is this request for continuation of a previous approval?

yes [go to item C]

no [skip item C; go to item D]

C.Has strength, dosage, or quantity required per day increased or decreased?

yes [go to item D]


no [skip item D; indicate rationale for continuation in Section IV and submit form]

D.Please indicate previous treatment and outcomes below.

Drug Name (include strength and dosage)

Dates of Therapy

Reason for Discontinuation





NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria.

IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)

Appropriate clinical information to support the request on the basis of medical necessity must be submitted.

Provider Signature:


US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.).

MHP Revised 01-2011

How to Edit Superior Prior Authorization Form Online for Free

Submitting documents together with our PDF editor is easier than nearly anything. To change prior auth request form superior the form, there is nothing you will do - just follow the actions down below:

Step 1: The initial step should be to select the orange "Get Form Now" button.

Step 2: You're now allowed to modify prior auth request form superior. You have a variety of options thanks to our multifunctional toolbar - you can add, erase, or modify the content, highlight its selected areas, as well as carry out many other commands.

For you to obtain the document, type in the information the software will ask you to for each of the following sections:

superior authorization form empty spaces to consider

The program will require you to complete the Expected length of therapy, Medication History for this, yes How Long, go to item B, no skip items B C go to item D, B Is this request for continuation, yes go to item C, no skip item C go to item D, C Has strength dosage or quantity, yes go to item D, no skip item D indicate rationale, D Please indicate previous, Drug Name include strength and, Dates of Therapy, and Reason for Discontinuation segment.

Filling in superior authorization form part 2

You'll be requested for some important details if you need to fill up the Appropriate clinical information, Provider Signature, Date, US Script will respond via fax or, and MHP Revised box.

superior authorization form Appropriate clinical information, Provider Signature, Date, US Script will respond via fax or, and MHP Revised blanks to fill out

Step 3: Hit the Done button to save your document. Now it is at your disposal for transfer to your device.

Step 4: Prepare copies of the file. This will protect you from upcoming misunderstandings. We don't look at or disclose your information, therefore feel comfortable knowing it will be protected.

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