PA Forms

Use the Prior Authorization Forms, available under the Rates and Billing section, for faxed PA requests including:

  • Certification of Need
  • FESP Initial Dialysis Case Creation Form
  • FESP Monthly Certification of Emergency Medical Condition
  • Prior Authorization Request Form
  • Prior Authorization Correction Form
  • Prior Authorization Medical Documentation Form
  • Optum Rx Prior Authorization Request Form
  • Recertification of Need