• Inpatient Admission Notification (pdf)
  This form is used to notify the health plan of an admission. *Please use the Mental Health/Chemical Dependency form located below for these specific admissions.
• Outpatient Preauthorization Request (pdf)
  This form is to request authorization for any upcoming procedure or service that is on our Preauthorization List. Use this form to request approval of upcoming procedures or services, even if an inpatient stay is anticipated.
• Durable Medical Equipment Preauthorization Request (pdf)

For these products or services requiring preauthorization, we recommend completing and submitting the applicable preauthorization form(s), otherwise submission of medical records will be required.

• Breast Reduction Preauthorization (Word)
• Mental Health / Chemical Dependency (pdf)
• Panniculectomy (Word)