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Request for Healthcare Preauthorization Form

Providers treating injured employees submit this simple form to request preauthorization for healthcare services.

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.