Regence BlueShield Pre-authorization information

Medical Pre-authorization Lists

Medical Pre-Authorization Forms

Form

Description

Instructions

Pre-authorization Request Form (PDF)

Pre-Authorization Fax Cover Sheet (for use when faxing the Pre-Authorization Request Form)

This form may be used to facilitate the pre-authorization process for medical, surgical or DME services.

	Complete all fields online.
	Print the form and submit by fax to 1 (800) 453-4341.
	Use the Pre-Authorization Fax Cover Sheet to fax your Request form.

This form may be used to facilitate the pre-authorization process for home health and ancillary therapies.

	Complete all fields online.
	ICD-9 code is required.
	Print the form and submit by fax to 1 (800) 453-4341.

This form is used to facilitate medical necessity for Oncotype Dx® Breast Cancer Assay. Codes include S3854 and 84999.

Fax completed forms to 1 (800) 453-4341

Note: To print a PDF document, you need Adobe^® Reader^®. Download it now for free.


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