Prior Authorization Request Form

The Prior Authorization Request Form is an enhanced, clinically focused template designed for medical practices, specialty pharmacies, hospitals, and utilization management departments that submit insurance pre-authorization requests for medications, procedures, diagnostic tests, and specialist referrals. Prior authorization remains one of the most significant administrative burdens in healthcare, with the average physician practice spending nearly two business days per week on prior auth tasks according to the AMA. This insurance pre-authorization form standardizes the submission process, ensuring that all required clinical and administrative data is captured in a single, organized document that reduces denials caused by incomplete information.

The form is structured to mirror the data fields that commercial insurers, Medicare Advantage plans, and Medicaid managed care organizations require in their prior authorization submissions. It begins with structured patient demographics and a comprehensive insurance information section that captures the plan name, member ID, group number, claims address, and pharmacy benefit manager details for medication prior authorizations. The clinical section includes fields for primary and secondary ICD-10 diagnosis codes, the specific procedure (CPT/HCPCS code) or medication (NDC, dose, frequency, duration) being requested, a detailed medical necessity justification narrative, documentation of previously tried and failed therapies (step therapy requirements), relevant lab results or imaging findings, and a supporting clinical documentation upload area for attaching chart notes, pathology reports, or letters of medical necessity.

This medication prior auth form is ideal for specialty practices that routinely manage complex authorization requirements, including oncology (biologic and immunotherapy agents), rheumatology (specialty medications), neurology (advanced imaging and specialty drugs), pain management (interventional procedures), cardiology (cardiac catheterization and device implantation), and orthopedics (surgical pre-certification). The form also serves hospital case management and utilization review departments processing inpatient and outpatient pre-certifications. By capturing all required data points in a structured digital format, practices can submit cleaner requests, track authorization status, reduce turnaround times, and maintain a complete audit trail of every prior authorization interaction with payers.