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Prior Authorization Request Forms

Standard PA Forms

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Standard PA Form (All Non-Opioid Drugs)

1 file(s) 109.30 KB
Download

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Acute Opioid Use PA Form (less than 90 days of opioid use)

1 file(s) 123.73 KB
Download

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Chronic Opioid Use PA Form (greater than 90 days of opioid use)

1 file(s) 217.49 KB
Download

State Forms

Arizona MRO 1.1 Form

VIEW

California DWC Form RFA

VIEW

Louisiana 1010 form

VIEW

New York Web Portal for Prior Authorizations

VISIT NY MEDICAL PORTAL or
NY MEDICAL PORTAL OVERVIEW

West Virginia Controlled Substance Form

VIEW
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