Download Medical Preauthorization Forms
For authorization, please download the appropriate form, answer each question, and print. Send the form and applicable patient chart notes to document clinical information. Fax the form back to the PEHP Case Management Department at 801-328-7449 or mail to:
PEHP Case Management560 East 200 South
Salt Lake City, UT 84102
If you have pre-authorization questions, call PEHP at 801-366-7555
This list 
shows some common services that require preauthorization.
This list shows medical codes with applicable policies that require preauthorization.
| Form Name | |
|---|---|
| (Intracept Procedure) Intra-Osseous Basivertebral Nerve Ablation Preauthoriation Form |  |
| Ambulatory and Video EEG Preauthorization Form | |
| Anesthesia Services for Dental Preauthorization Form | |
| ART Verification Form | |
| Breast Surgery Preauthorization Form | |
| Capsule Endoscopy Preauthorization Form | |
| Cardiac Catheter Ablation and Radioablation Preauthorization Form | |
| Cochlear Implants, Auditory Brainstem Implants, & Bone Anchored Hearing Aids (BAHA) Preauthorization Form | |
| Cranial Orthotic Devices Preauthorization Form | |
| Dental Services – General – Preauthorization Form | |
| Dental Services – Single-Tooth Prosthodontic Restoration – Preauthorization Form | |
| Eating Disorders - Inpatient Level of Care Preauthorization Form | |
| Eating Disorders - Residential Level of Care Preauthorization Form | |
| Gender Reassignment Surgery Preauthorization Form | |
| Genetic Testing - Breast Cancer Prognosis Testing Preauthorization Form | |
| Genetic Testing - Prostate Cancer Prognosis Testing Preauthorization Form | |
| Genetic Testing Preauthorization Form | |
| Hypoglossal Nerve Neurostimulation Preauthorization Form | |
| Inpatient Rehabilitation and SNF Preauthorization Form | |
| Intervertebral Disc Prostheses Preauthorization Form | |
| Long Term Acute Care Preauthorization Form | |
| Mechanical Stretching Devices for Contracture and Joint Stiffness Preuthorization Form | |
| Medical/Case Management Medication Preauthorization Form | |
| Medical-Surgical Services Preauthorization Form | |
| Mental Health Services Preauthorization Form | |
| Miscellaneous Durable Medical Equipment Preuthorization Form | |
| Neurolysis and Pain Management Procedures Preuthorization Form | |
| Nutritional Support Preauthorization Form | |
| Orthognathic Surgery Preauthorization Form | |
| Panniculectomy Preauthorization Form | |
| PEHP Autism Services Preauthorization Form | |
| PEHP Hearing Aids Preauthorization Form | |
| Prothrombin Time (INR) Home Testing Device Preauthorization Form | |
| Psychiatric & Substance Abuse - Residential Level of Care Preauthorization Form | |
| Radiation Therapy Preauthorization Form | |
| Rhinoplasty Preauthorization Form | |
| Sacroiliac Joint Fusion Preauthorization Form | |
| Sleep Testing Preauthorization Form | |
| Spinal Cord Stimulator and Dorsal Root Ganglion Stimulator Preauthorization Form | |
| Total Ankle Arthroplasty - Replacement Preauthorization Form | |
| Transcranial Magnetic Stimulation and Cranial Electrical Stimulation Preauthorization Form | |
| Uvulopalatopharyngoplasty (UPPP) Preauthorization Form | |
| Vagus Nerve Stimulation Preauthorization Form | |
| Varicose Vein Treatment Preauthorization Form | |
| Wearable Cardioverter-Defibrillators Preauthorization Form | |
| Wound Care Preauthorization Form | |