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Prior Authorization Form Template

Streamline Your Patient Authorization Process with Ease

Navigating prior authorizations can feel overwhelming and time-consuming. This prior authorization form template is designed to assist healthcare providers like you in efficiently obtaining necessary approvals for medications and medical procedures. You'll simplify the paperwork process, reduce delays in patient care, and ensure compliance with insurance requirements, all while enhancing communication with insurance companies. Plus, with built-in WCAG-aligned labels, you'll make your forms accessible to everyone. Start using this live template to improve your workflow today.

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Patient full name
Date of birth
Patient phone number
Patient address
Insurance plan name
Member ID
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Requesting/ordering provider full name
NPI
Practice/organization name
Provider phone
Provider fax
Servicing provider/facility/pharmacy name
NPI or NCPDP
Servicing phone
Servicing fax
Service location type
Office
Outpatient hospital
Inpatient hospital
Ambulatory surgery center
Home
Telehealth
DME supplier
Pharmacy
Other
Please Specify:
Service type requested
Medication
Procedure
Diagnostic test
Medical device/DME
Therapy
Other
Please Specify:
Urgency
Routine
Expedited/Urgent
Requested start date
Primary diagnosis code(s) (ICD-10)
Procedure/Drug code(s) (CPT/HCPCS/NDC)
Requested service/item description
Dosing or quantity and frequency
Is this request related to a work injury or auto accident?
Yes
No
Relevant clinical findings, labs, and imaging
Contraindications, allergies, or comorbidities
Previous treatments tried and outcomes (include dates and durations)
Will you submit supporting documents separately (fax, portal, or upload)?
Yes
No
List attached or forthcoming documents (e.g., chart notes, labs, imaging, treatment history)
Preferred method for determination notice
Fax
Phone
Email
Mail
Portal
I attest that the information provided is accurate and medically necessary to the best of my knowledge.
True
False
Authorized signer name (type full name)
Date signed
I have obtained any required patient authorization to release medical information for this request.
Yes
No
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Paper art illustration depicting a prior authorization form template for FormCreatorAI article.

When to use this form

Use this template when a health plan must approve care before you schedule or dispense it. It fits medical practices, imaging centers, pharmacies, and behavioral health clinics. Typical cases include specialty medications, advanced imaging, durable medical equipment, and out-of-network referrals. Add clinical notes and insurer details to speed decisions and cut denials. If you also need to route internal sign-offs, pair it with an Authorization request form. For remote visits that require pre-approval, collect patient permission with a Telehealth consent form so records stay complete. The result: fewer faxes, faster responses from payers, and clear documentation your team can track.

Must Ask Prior Authorization Questions

  1. What diagnosis or ICD-10 code supports this request?

    Plans check medical necessity against the diagnosis. A clear code helps reviewers match criteria and approve faster.

  2. Which service, medication, or device are you requesting, including CPT/HCPCS and dosage?

    Specific codes and details prevent ambiguity and rework. It also ensures the approved item matches what you will provide.

  3. What is the requested place of service and the start and end dates?

    Insurers authorize care for certain settings and time frames. Accurate dates and location avoid denials for the wrong site or expired periods.

  4. What prior treatments were tried, and what were the outcomes?

    Documenting step therapy or in-network alternatives shows you followed policy. This evidence reduces back-and-forth and supports medical necessity.

  5. Is the patient a minor or dependent, and do you have documented consent?

    When a caregiver must sign, attach proof to avoid delays. If you need a separate consent, use a Child medical consent form.

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