Pre-authorization Forms

• Medical Pre-authorization Form - used when a condition requires a pre-authorization.
• Pre-authorization Fax Cover Sheet - used when faxing the Pre-Authorization form.

Pharmacy prior authorization
Pharmacy prior authorization information and forms can be found at the RegenceRx Physician Web site.

Investigational services and supplies
Pre-authorization for investigational services and supplies is required. Charges for investigational services and supplies are denied as provider write-offs unless the patient agrees in writing prior to receiving services to be financially responsible for the charges.

• View investigational and potentially investigational procedures on the current Asuris Clinical Edits by Code list.
• View a sample non-covered services waiver form (PDF).