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Medicare Prior Authorization Form Template

Streamline Your Medicare Approval Process with This Template

Navigating the Medicare authorization process can be challenging, especially when you're trying to secure timely approvals for necessary treatments. This Medicare prior authorization form template is designed for healthcare providers seeking efficient ways to request approval from Medicare for their patients' procedures. With clear sections for patient information, treatment details, and provider signatures, this template helps reduce processing time, ensures compliance with guidelines, and enhances communication with insurance providers-all while being WCAG-aligned for accessibility. Explore how you can simplify your workflow by using this live template now.

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Patient full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Medicare Beneficiary Identifier (MBI)
Medicare coverage type
Original Medicare (Part A and Part B)
Medicare Advantage (Part C)
Medicare Part D (standalone PDP)
Medicare Supplement (Medigap)
Not sure
Do you have secondary insurance?
Yes
No
Secondary insurance name (if applicable)
Patient phone
Patient email
Patient address
Height (with units)
Weight (with units)
Allergies (if any)
Is the patient currently hospitalized?
Yes
No
Requesting provider or group name
NPI (National Provider Identifier)
Tax ID (TIN)
Contact person
Contact phone
Fax
Contact email
Provider address
Servicing provider or facility name
Servicing NPI
Servicing phone
Servicing fax
Servicing address
Place of service
Inpatient hospital
Outpatient hospital
Office
Ambulatory surgical center
Skilled nursing facility
Home
Telehealth
Other
Please Specify:
Type of request/service
Please Specify:
Reason for expedited request (if applicable)
Proposed start date of service
Number of visits or units requested
Length of stay or duration requested
Primary diagnosis code(s) (ICD-10)
Procedure/HCPCS/CPT code(s)
Modifiers (if applicable)
Is this an expedited (urgent) request?
Yes
No
Medication name
Strength and dosage form
Directions for use (sig)
Quantity per fill
Days supply per fill
Refills requested
Prior therapies tried and outcomes
Known contraindications or adverse reactions
Have required step therapies been tried?
Yes
No
Clinical rationale and medical necessity summary
Relevant lab or imaging results summary
How will supporting documentation be provided?
Fax
Secure upload or portal
Not applicable
Submitter full name
Role or title
Organization
Best contact phone
Best contact email
Typed signature of requester
Signature date
I attest that the information provided is accurate and that required patient consent to release medical information has been obtained.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Gender","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a Medicare prior authorization form template for FormCreatorAI article

When to use this form

This form helps you request plan approval before providing care, supplies, or drugs. Use it when scheduling imaging (MRI/CT), outpatient surgery, specialty infusions, DME, home health, or non-emergency transport. It is useful for clinics, pharmacies, and suppliers that must show medical necessity, as well as patients who want to avoid surprise denials. Include member, provider, diagnosis, and procedure details so the plan can decide quickly. If you need a general approval outside of Medicare plans, use the Authorization request form. For urgent treatment where consent is required, pair it with an Emergency medical consent form. For minors or dependents, you may also need a Pediatrics medical release form to share records.

Must Ask Medicare Prior Authorization Questions

  1. What is the member's full name, date of birth, Medicare ID, and plan type?

    Accurate member and plan details route the request to the right payer rules and verify eligibility. Getting this wrong causes delays or denials before review even starts.

  2. Which service or item are you requesting, including CPT/HCPCS codes and number of units?

    Specific codes map the request to coverage policies and let reviewers price the benefit. Clear units prevent partial approvals or costly resubmissions.

  3. What is the diagnosis and clinical rationale, including past treatments tried and failed?

    Explaining medical necessity shows why the service is needed now. Attach recent notes, imaging, and labs so reviewers can confirm the criteria without back-and-forth.

  4. Who are the requesting and rendering providers, with NPI, TIN, contacts, and facility location?

    Complete identifiers tie the authorization to the correct clinicians and site of care. This reduces misrouted faxes, call-backs, and claim mismatch later.

  5. What are the requested dates, urgency (standard or expedited), and place of service?

    Timing and urgency help the plan triage the review and meet response deadlines. Stating inpatient, outpatient, office, or home care flags the correct coverage rules.

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