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Request for Healthcare Preauthorization Form


This form facilitates preauthorization requests for healthcare services, procedures, and durable medical equipment. Providers must include clinical documentation and signed orders. 

If a treatment or service request is denied, we will tell you in writing. This written notice will have information about your right to request a reconsideration or appeal of the denied treatment. It will also tell you about your right to request review by an Independent Review Organization through the Texas Department of Insurance.