Medical Forms

We’re simplifying our prior authorization forms and fax lines to make submissions easier. Two new forms—one for inpatient and one for outpatient requests—will replace the multiple existing forms available here.

We’re also streamlining our fax lines to one dedicated number per line of business. Learn more.

Authorization/Extension Requests

NEW: Inpatient Authorization Request

NEW: Outpatient Authorization Request

ABA Request for Authorization Form

Air Ambulance Authorization Form

Behavioral Health Inpatient Authorization Form

Behavioral Health Inpatient Concurrent Review Request

Behavioral Health Outpatient Authorization Form

Durable Medical Equipment Authorization

Home Care Authorization

Hospice Authorization

Infertility Pre-Treatment Form

Infusion Therapy Authorization

Outpatient Pre-Treatment Authorization Program (OPAP) Request

Precertification Request for Authorization of Services

Post-Acute Care Authorization Form

Continuity of Care - Members in a Maryland Based Plan (PDF)

Continuity of Care - Provider Not in Network (PDF)

Maryland Uniform Treatment Plan Form

Utilization Management Request for Authorization Form

NICU Precertification Form