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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 Management, 560 East 200 South Salt Lake City, UT 84102. If you have pre-authorization questions, call PEHP at 801-366-7555

» Amino Acid-Based Formula Preauthorization Form PDF file

» Ambulatory & Video EEG Preauthorization Form PDF file

» Anesthesia Services for Dental Procedures under Medical Preauthorization Form PDF file

» Anesthesia Services for Gastrointestinal Endoscopic Procedures Preauthorization Form PDF file

» Anesthesia Services - Non-Standard Place of Service Preauthorization Form PDF file

» ART Verification Form PDF file

» Autism Program Preauthorization Form PDF file

» Bone Growth Stimulators Preauthorization Form PDF file

» Breast Reconstruction Preauthorization Form PDF file

» Capsule Endoscopy Preauthorization Form PDF file

» Chest Physiotherapy & Airway Clearance Devices Preauthorization Form PDF file

» Cochlear Impants, Auditory Brainstem Implants, Bone Anchored Hearing Implants (BAHA) Preauthorization Form PDF file

» Cognitive Speech & Voice Therapy Preauthorization Form PDF file

» Cranial Orthotic Devices Preauthorization Form PDF file

» Eyelid Surgery Preauthorization Form PDF file

» Genetic & Specialty Laboratory Testing Preauthorization Form PDF file

» Hearing Aids Preauthorization Form PDF file

» Home Health & Hospice Preauthorization Form PDF file

» Inpatient Rehabilitation & Skilled Nursing Facility Preauthorization Form PDF file

» Intervertebral Disc Prostheses Preauthorization Form PDF file

» Long-Term Acute Care Preauthorization Form PDF file

» Mechanical Stretching Devices For Contracture & Joint Stiffness Preauthorization Form PDF file

» Medical/Case Management Medication Preauthorization Form PDF file

» Medical/Surgical Services Preauthorization Form PDF file

» Mental Health Services Preauthorization Form PDF file

» Minimally Invasive Fusion of Sacroiliac Joint Preauthorization Form PDF file

» Miscellaneous Diagnostic Testing Preauthorization FormPDF file

» Neurolysis and Pain Management Procedures Preauthorization Form PDF file

» Nutritional Support Preauthorization Form PDF file

» Orthognathic Surgery Preauthorization Form PDF file

» Outpatient Physical & Occupational Therapy Preauthorization Form PDF file

» Panniculectomy Preauthorization Form PDF file

» Prothrombin Time (INR) Home Testing Device Preauthorization Form PDF file

» Radiation Therapy Preauthorization Form PDF file

» Rhinoplasty Preauthorization Form PDF file

» Sleep Testing Preauthorization Form PDF file

» Spinal Cord Stimulator & Dorsal Root Ganglion Stimulator Preauthorization Form PDF file

» Transcranial Magnetic Stimulation and Cranial Electrical Stimulation Preauthorization Form PDF file

» Total Ankle Arthroplasty Preauthorization Form PDF file

» Uvulopalatopharyngoplasty Preauthorization Form PDF file

» Vagus Nerve Stimulation Preauthorization Form PDF file

» Varicose Vein Treatment Preauthorization Form PDF file

» Wearable Cardioverter-Defibrillators Preauthorization Form PDF file

» Wound Care Preauthorization Form PDF file