Pre-authorization Forms
For your convenience, the following forms may be used to facilitate the pre-authorization process.

• Pre-authorization Request Form (PDF) for medical, surgical or DME services
• Pre-authorization Information Form (PDF) for home health and ancillary therapies

Pharmacy prior authorization
Pharmacy prior authorization information and forms can be found at the RegenceRx Physician Web site.

Investigational services and supplies
Pre-authorization for investigational services and supplies is required. Charges for investigational services and supplies are denied as provider write-offs unless the patient agrees in writing prior to receiving services to be financially responsible for the charges.

• View investigational and potentially investigational procedures on the current Regence Clinical Edits by Code list.
• View a sample non-covered services waiver form (PDF).

Note: To view and print the documents listed on this page, you must have the Adobe® Acrobat® Reader installed. Get more information and/or download the free Adobe Acrobat Reader.