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Requires submitting medical rationale, prior drug trials, ICD-9/ICD-10 diagnosis codes, and supporting clinical documentation such as history and physical, lab or testing results, symptoms, functional impairments, and chart notes.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/oregon-state-pa-request-form-pre-authorization-prescription-request-form/283844/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/oregon-state-pa-request-form-pre-authorization-prescription-request-form/283844.png","ImageObject",442,249,{"name":42,"@type":43},"\tWilliam","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-20","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who should complete the pre-authorization request form and what must be verified before submission?","Question",{"text":63,"@type":64},"The provider should fill out the form. Before completing it, confirm the patient’s benefits and eligibility and follow verification steps via the preauthorization list or the member card number.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"When is a request considered urgent on this form?",{"text":68,"@type":64},"It is urgent if delaying service could seriously jeopardize the life/health of the member or their ability to regain maximum function, or if a physician believes it would subject the member to severe pain that cannot be adequately managed without the disputed care or treatment.",{"name":70,"@type":61,"acceptedAnswer":71},"What clinical and coding information must be provided with the medication request?",{"text":72,"@type":64},"Provide the medical rationale for the requested drug, prior drug trials, and all available ICD-9 or ICD-10 diagnosis codes with descriptions. Include supporting clinical information such as history and physical, lab/radiology results, current symptoms and functional impairments, treatment history, and chart notes supporting medical necessity.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283844,1789620796,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":22},5909887254083,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Plan name:   Address:   City:   State:   ZIP:    \nPhone:  \nEmail:  \nInstructions: This pre-authorization request form should be filled out by the provider. Before completing this form, please confirm the patient’s benefits and eligibility. Benefits for services received are subject to eligibility and plan terms and conditions that are in place at the time services are provided.  \nIs this request urgent? Defined as: A delay of service could seriously jeopardize the life or health of the member or the ability of the member to regain maximum function.–Or– In the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the disputed care or treatment. If this request is urgent and meets the definition as indicated above, please check this box.  \n Urgent request  \nDate:  \n/  \n/  \nUniform Prior Authorization Prescription Request Form  \nVerify with thepreauthorization list on the [“One Health Port” hyperlink], according to the company's procedure, or call the number on the back of the member's card.  \nIs this request:  New  Authorization extension  Providing additional information  \nIf you already have an authorization number, list it here:    \n1. Patient information  \nName Last:   First:   MI:   Member ID \\#:   and Group number:    \nSecondary insurer member ID \\#: and Group number:  \nHeight:   Weight:   \nMale  \nFemale  \nDOB:  \n/ /  \nAllergies:    \n2. Prescriber / Provider information  \nCheck one: You are the  Requesting provider  Servicing provider  Specialty:   Provider:  \nname:   Tax ID number:    \nNPI:   DEA number (if required):    \nProvider address:   Who should we contact if we require more information? Name:    \n440-4992 5/ 15/COM) 1  \n3. Patient's PCP information (if applicable)  \nName:  \nPhone:  \n\n|  | - |  | - |  | ext. |  | Fax: |  | - |  | - |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\n4. Medication / Medical and Dispensing Information  \nMedication name:   Dose/strength:   Frequency:   Length of therapy/\\#refills:   /   Quantity:    New therapy  Renewal If Renewal: date therapy initiated  \nRoute of administration:  Oral/SL  Topical  Injection  IV  Other:   Administered:  Doctor’s office  Dialysis center  Home health  By patient  Other:    \nList of previous drugs tried  \nDrug name: Dosage:  \nProvide the medical rationale for requested drug (inlude chart notes and supporting labs) and why a formulary alternative is not acceptable:  \nProvide all ICD-9 or ICD-10 codes and their descriptions, if available; this will help us process your request.  \nDiagnosis:   Codes and descriptions are:  ICD-9  ICD-10  \nPrimary:   Second:    \nThird:  \nSubmit the following clinical information with this form as appropriate for this request: History & Physical • Lab/radiology/testing results • Current symptoms and functional impairments • Treatment history • Any other information such as chart notes that support medical necessity for the request. [Hyperlink to Plan's Pharmacy Policy]  \n440-4992 (5/15/COM) 2","cbCairnlUR7M3RHs","https://ap.wps.com/l/cbCairnlUR7M3RHs","pdf",219489,"English","# Patient information\n## Prescriber / Provider information\n## Patient's PCP information (if applicable)\n## Medication / Medical and Dispensing Information","[{\"question\":\"Who should complete the pre-authorization request form and what must be verified before submission?\",\"answer\":\"The provider should fill out the form. Before completing it, confirm the patient’s benefits and eligibility and follow verification steps via the preauthorization list or the member card number.\"},{\"question\":\"When is a request considered urgent on this form?\",\"answer\":\"It is urgent if delaying service could seriously jeopardize the life/health of the member or their ability to regain maximum function, or if a physician believes it would subject the member to severe pain that cannot be adequately managed without the disputed care or treatment.\"},{\"question\":\"What clinical and coding information must be provided with the medication request?\",\"answer\":\"Provide the medical rationale for the requested drug, prior drug trials, and all available ICD-9 or ICD-10 diagnosis codes with descriptions. Include supporting clinical information such as history and physical, lab/radiology results, current symptoms and functional impairments, treatment history, and chart notes supporting medical necessity.\"}]","Oregon State PA Request Form - Pre-authorization Prescription Request Form | PDF"]