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 services and supplies currently considered investigational.
• View a sample non-covered services waiver form (PDF).