Provider forms

Forms for medical providers

Arkansas Formulary Exception/Prior Approval Request Form

Authorization | Organizational Determination Request Form
You may use this form in two cases:

1. When a prior authorization is required.
2. When a prior authorization is not required but a decision is needed. In this case, you can use the "Org Determination/Benefit Inquiry Only" option on the "Request Type" field.

Transplant Prior Authorization/Organizational Determination Form Use for transplant services.