Prior Authorization Forms & Manuals

Advanced Imaging Prior Authorization Request Form

Amyloid Therapies for Alzheimer's Disease Prior Authorization Request Form

Corneal Remodeling Procedures Prior Authorization Request Form

Donor Breast Milk Prior Authorization Request Form

Gene Based Therapy for Duchenne Muscular Dystrophy (DMD) Form

Genetic Testing Prior Authorization Request Form

Inpatient Acute Rehabilitation and Chronic Disease Hospital (CDH) Request Form

For all inpatient admissions requests to Acute Rehabilitation and Chronic Disease Hospital; complete and fax the form to 203.774.0551.

Inpatient Chemotherapy Request Form

For all elective inpatient chemotherapy admissions requests, please complete and fax the form to 203.265.3994.

Inpatient Surgery/Procedure Request Form

For all elective inpatient admissions requests, such as preoperative day admissions, elective inpatient surgeries, and elective medical procedures; complete and fax the form to 203.265.3994.

LUXTURNA™ (voretigene neparvovec-rzyl) Prior Authorization Request Form

Organ Transplant Prior Authorization Request Form

Outpatient Prior Authorization Request Form

Authorization requests for home care must be submitted through the Medical Authorization Portal. Outpatient hospital-based therapy may be requested via fax to 203.265.3994.

Palivizumab (Synagis^®) Prior Authorization Request Form

For use by clinics and private practices.

Palivizumab (Synagis^®) Outpatient Hospital Prior Authorization Request Form

For information on the coverage guidelines and procedures for requesting authorization for Palivizumab (Synagis^®), please refer to the clinical policy located on our Policies, Procedures & Guidelines page.

Spinraza™ (nusinersen) Prior Authorization Request Form

For information on the coverage guidelines and procedures for requesting authorization for Spinraza™ (nusinersen) please refer to the clinical policy located on our Policies, Procedures & Guidelines page.

Tepezza^®: Prior Authorization Request Form

For information on the coverage guidelines and procedures for requesting authorization for Tepezza^®: please refer to the clinical policy located on our Policies, Procedures, & Guidelines page.

Wheeled Mobility Device Guidelines

Wheeled Mobility Letter of Medical Necessity Form (PDF version)

Wheeled Mobility Letter of Medical Necessity Form (MS Word version)

Wheeled Mobility Accessibility Survey

Whole Exome Sequencing and Whole Genome Sequencing Prior Authorization Request Form

Zolgensma^® Prior Authorization Request Form

Zulresso™ (brexanolone) Prior Authorization Request Form