Prior Authorization Forms | Providers | Sentara Health Plans

Pre-authorization reconsideration request? Please submit the Reconsideration of a Denied Pre-Authorization form.

Advanced Imaging

Advanced Imaging
PDF, 90 KBLast Updated: 01/17/2024
PDF, 90 KBLast Updated: 01/17/2024

Behavioral Health

ABA Authorization
PDF, 242 KBLast Updated: 12/21/2023
PDF, 242 KBLast Updated: 12/21/2023
Behavioral Health Discharge Summary
PDF, 96 KBLast Updated: 12/21/2023
PDF, 96 KBLast Updated: 12/21/2023
Behavioral Health Inpatient Authorization Request
PDF, 135 KBLast Updated: 12/21/2023
PDF, 135 KBLast Updated: 12/21/2023
Behavioral Health Outpatient Authorization Request
PDF, 136 KBLast Updated: 12/21/2023
PDF, 136 KBLast Updated: 12/21/2023
Electroconvulsive Therapy (ECT) Authorization Request
PDF, 169 KBLast Updated: 12/21/2023
PDF, 169 KBLast Updated: 12/21/2023
Transcranial Magnetic Stimulation (rTMS) Authorization Request Form
PDF, 270 KBLast Updated: 12/29/2023
PDF, 270 KBLast Updated: 12/29/2023

Durable Medical Equipment

DME Authorization
PDF, 106 KBLast Updated: 12/21/2023
PDF, 106 KBLast Updated: 12/21/2023

Home Health

Home Health Authorization - Commercial Plans
PDF, 105 KBLast Updated: 12/22/2023
PDF, 105 KBLast Updated: 12/22/2023
Home Health Nutrition Authorization - Commercial Plans
PDF, 100 KBLast Updated: 12/22/2023
PDF, 100 KBLast Updated: 12/22/2023
Authorization Request for Outpatient Intravenous Therapy - Commercial Plans
PDF, 103 KBLast Updated: 12/22/2023
PDF, 103 KBLast Updated: 12/22/2023

Inpatient and Outpatient Observation

Authorization Request for Currently Hospitalized Members (Inpatient or Observation)
PDF, 121 KBLast Updated: 12/21/2023
PDF, 121 KBLast Updated: 12/21/2023
Commercial Plans: Authorization for Future Inpatient and Outpatient Services
PDF, 107 KBLast Updated: 12/21/2023
PDF, 107 KBLast Updated: 12/21/2023

Radiology and Oncology

Chemotherapy Administration Medical Policy 316
PDF, 131 KBLast Updated: 11/29/2023
PDF, 131 KBLast Updated: 11/29/2023
Policy for Oncology use for WBC Growth Factor
PDF, 246 KBLast Updated: 12/16/2023
PDF, 246 KBLast Updated: 12/16/2023

Therapy Authorization Worksheet

Outpatient Physical Occupational-Speech Therapies
PDF, 120 KBLast Updated: 12/21/2023
PDF, 120 KBLast Updated: 12/21/2023

Transitional Care Request

Transitioning Care to Sentara Health Plans
PDF, 171 KBLast Updated: 12/05/2023
PDF, 171 KBLast Updated: 12/05/2023

Urgent Request

Authorization for Urgent Services
PDF, 133 KBLast Updated: 12/21/2023
PDF, 133 KBLast Updated: 12/21/2023