Health Net Prior (Rx) Authorization Form

Updated December 31, 2021

A Health Net prior authorization form is a document that medical offices will use when requesting coverage of a patient’s prescription. Certain insurance policies may not cover all prescriptions, usually, those that are highly expensive, thus approval from Health Net must be received before a prescription can be written. This form needs to be filled in by the medical staff and submitted to Health Net for review.

  • Arizona DME Fax Request: DME 1 (800) 916-8996
  • Arizona General PA: 1 (800) 840-109
  • California Request: Fax 1 (800) 793-4473 or call 1 (800) 672-2135
  • Oregon/WA Medicare Fax Request: 1 (866) 295-8562
  • Oregon/WA Commercial Fax Request: 1 (800) 495-1148

 How to Write

Step 1 – Select one of the options in the box at the top of the page to specify where your submission will be sent.

Step 2 – In “Member Information”, enter the member’s name, date of birth, and subscriber number.

Step 3 – In “Check the appropriate box (Product)”, check the box that’s associated with your prescription type.

Step 4 – In “Designate type of request”, specify the type of request being made and explain the clinical necessity for urgent/expedited request (if any).

Step 5 – In “Designate service request”, specify the type of services to be rendered and give the anticipated date of service.

Step 6 – In “Requesting/Ordering Provider Information”, supply the following requester/provider information: first and last name, Tax ID/NPI, full address, telephone and fax number, and requesting/ordering contact name. Also, give the name of the primary care physician (if applicable) along with their area code, telephone number, and fax number.

Step 7 – In “Servicing Provider – Where will member receive services?”, supply the following provider information: organization name, Tax ID number, National Provider Identifier, full address, and telephone number. Specify whether or not an assistant surgeon is required by selecting yes or no (if yes, give the surgeon’s name and Tax ID/NPI). Lastly, select yes or no to specify whether an anesthesiologist is required.

Step 8 – In “Clinical Information”, supply the ICD-10 code(s), diagnosis description, and the date of onset/injury. Below that, enter the CPT code(s), number of visits, and describe the services requested.

Step 9 – In “Clinical Information”, explain why the requested service is necessary.

Step 10 – In “Clinical Information”, select yes or no to specify whether the individual is mentally ill. Also, select yes or no to specify whether the individual is aware of a mental illness (if applicable).

Step 11 – In “Clinical Information”, the requesting physician must give their signature and date the document.