• Group and Individual Products
• Medicare Products (Regence MedAdvantage and Medicare Part D Prescription Drug Plans)
• Federal Employee Program (FEP)
• Uniform Medical Plan
• Regence Rx

Pre-authorization Request Form

Medical, surgical or DME services:

• Secure online form
• PDF version to print and fax

Home Health and Ancillary Therapies:

• PDF version to print and fax

This form is used when a condition requires a pre-authorization. A limited number of services require a pre-authorization.

Submit completed forms:

Statement of Medical Necessity for Oncotype DX (PDF)

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

This form is for Federal Employee Program (FEP) members. 

Call FEP Customer Service at 1 (877) 668-4654 in order to verify the type of coverage, benefits, eligibility, co-payments, and deductible.

This form is for members who require an authorization for behavioral health outpatient treatment, including chemical dependency.

Submit this form to Regence for authorization of continued services.

Please call Regence Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions. 

Complete the Treatment plan request form securely online or you may download the form (PDF) and submit by fax to Regence Behavioral Health 1 (888) 496-1540.