Providence Prior (Rx) Authorization Form

Updated January 24, 2022

Providence prior authorization form allows a physician to request coverage for a medication that their patient is not covered for with their Providence Health Plan. Within this form, they will need to justify their reasons for making this request and detail trials and tests which led to their diagnosis and resultant request. If you need to fill out a Providence prior authorization form for either medications or medical services, you can download fillable PDF versions of these forms on this page, and you will also find the fax numbers required for delivery purposes.

How to Write

Step 1 – In Patient Information, you must supply the patient’s full name, member ID, and date of birth.

Step 2 – Next, in Requesting Provider Information, you will need to provide your complete name, your specialty, your NPI number, your Tax ID number, your complete address, and your fax and phone number. Next, enter a contact and the relevant pharmacy name, as well as a phone number and a fax number for both.

Step 3 – In Drug Information, enter the name, strength, quantity, ICD-9, directions for use, length of therapy, and the related diagnosis of the requested medication. Below that, you will need to list the name and dosage of any medications that have previously been tried to treat this patient for the relevant diagnosis. You will also need to provide your rationale for making this request and why you cannot use a preferred drug instead.

Step 4 – To complete filling out this form, you must provide your signature and the date.