Forms & Prior Auth List Notices

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Prior Auth Lists, Requirements and Notice of Changes

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Prior Authorization Request Forms

• Medical Prior Authorization Request Form
• Molecular Pathology Request Form
• Electronic Claim Fax Cover Sheet
• Prior Authorization for SUD Form
• Prior Authorization for Drug Screening Form
• Authorization to Disclose Health Information to Primary Care Providers
• Continuity of Care Consultation Sheet
• Request for ECT/TMS
• THP Gold Star Program
• Treatment Continuation Request Form