- Adult Day – Enhanced (Reference Guide for Adult Day Services Requests)
- Assisted Living
- Behavioral Health Services
- Breast Reduction
- Gastric Bypass
- General Auth Request Form
- Genetic Testing
- Home Care Services – (Home Care Prior Authorization Form Guide)
- Home Infusion
- Hospice
- In Lieu of Form
- INTEGRA DME Authorization Request Form
- Minimum Data Set (MDS) for Home Care form
- Non-Emergency Ambulance Transportation Form
- Out of Network Authorization Request Form (For Transplant and Behavioral Health requests, please use the specific prior authorization form for the service, not the out-of-network prior authorization form)
- Outpatient Rehab – Adult/Pedi
- Outpatient Surgery – Request/Checklist
- Pain Management Request Form
- Prenatal Request Form
- Sleep Study Request Form
- SNF/Auth Rehab/LTAC Request Form (Initial Request ONLY)
- Spinal Cord Simulator Request Form
- Termination of Pregnancy Form (preservation of mother’s life)
- Termination of Pregnancy Form (rape or incest)
- Transplant Checklist
Think before you print! Does your request require prior authorization?
In an effort to save you time and reduce administrative burden, please consult the new Neighborhood Prior Authorization Search Tool, by member line of business, before submitting a PA request.
With a quick search function by procedure/service code, the PA Search Tool displays any authorization requirements. Start saving time today!
Last updated: April 23, 2026 @ 2:25 pm