Authorization Forms

Providers can click the authorization form they need to download it. Instructions on how/where to submit the completed form are included at the bottom of the form itself.

• Applied Behavior Analysis (ABA) request forms
  • Applied Behavior Analysis Service request form
  • Functional Behavioral Assessment request form
  • Assistive Communication Device request form
• Bariatric Authorization form
• Blepharoplasty Authorization form
• Breast Reduction Authorization form
• Cuprimine/Disotate/Endrate (or other chelating drug) Authorization form
• Dialysis Authorization form
• Durable Medical Equipment (DME) Authorization form
• Experimental/Investigational and Cosmetic Authorization form
• Gender Reassignment Surgery Authorization form
• Nasal Surgeries Authorization form
• Osteochondral Authorization form (Including Grafting and Autologous Cultured Chondrocyte Implantation)
• Pain Management Authorization form
• Panniculectomy/Abdominoplasty Authorization form
• Prosthetic Device Authorization form
• Psychological or Neuropsychological Testing Authorization form
• Sleep Study (In-Lab/Attended) Authorization form
• Spinal Surgery Authorization form
• Therapy Services Authorization form
• Total Parenteral Nutrition (TPN)/Intradialytic Parenteral Nutrition (IDPN) Authorization form
• Transcranial Magnetic Stimulation/Electroconvulsive Therapy (TMS/ECT) Authorization form
• Vein Surgeries Authorization form
• Wound Care Authorization form