SelectHealth Prior (Rx) Authorization Form

Updated January 23, 2022

SelectHealth prior authorization form is a form used by a physician to request a specific medication/treatment for their patient, one that is otherwise not covered by the patient’s insurance plan. SelectHealth needs to make sure that the doctor has considered other options for treating their patient and that this particular treatment is the only viable option to improve their patient’s condition. Upon completion of the SelectHealth prior authorization form, the physician can fax or mail it to SelectHealth so that the insurance company can determine whether to sanction this request. Physician’s should include as much information concerning their diagnoses and medical reasoning as possible in order to establish a sound argument.

  • Form can be faxed to: 1 (866) 610-2775

How to Write

Step 1 – Section (1) of the SelectHealth prior authorization form asks for the provider’s information. Include the presciber’s name, NPI#, specialty, phone number, address, office contact name, fax#, pharmacy name, and pharmacy phone number.

Step 2 – In “Member Information”, enter the member’s name, the current date, their ID#, D.O.B., drug allergies, and select “First Choice by Select Health” from the drop down menu.

Step 3 – Provide the necessary drug information under section (3), including the drug name, strength, dosage form and interval, and quantity. Next, provide a diagnosis, the appropriate code, length of therapy, and number of refills.

Step 4 – Section (4) asks for background information on the medication in question. Provide the following information: where the drug is to be administered, whether the patient is currently being treated with the drug, if the request is a continuation request, whether there’s been a decrease or increase in the medication, and include previous treatments along with the effects of these medications.

Step 5 – A large field is provided in section (5) for any information that might help convince SelectHealth to approve their request for the medication in question.

Step 6 – Prescriber must provide their signature and the current date.