Service Authorization/Notification Forms – Print
If you are unable to access online forms, Service Authorization requests can be submitted using the printable forms below.
- Medical Service Authorization Request Form
- Enteral Nutrition Service Authorization Form
- Inpatient – Admission/Discharge Authorization Request Form (to be used by out-of-network or out-of-state providers)
- Mental Health-Targeted Case Management (MH-TCM) Service Authorization Request Form
- Restricted Recipient Program (RRP) Referral Form
- Children's Residential Mental Health (Rule 5) Treatment Facility Notification Form
- PRTF Eligibility for Admission
- PRTF Individual Plan of Care and Authorization
- PRTF Extended Leave Request
Updated_04/03/2024
