Provider forms

Forms for medical providers

• Arkansas Formulary Exception/Prior Approval Request Form
• Authorization | Organizational Determination Request Form You may use this form in twocases:
  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.
• Exception FormUse the exception form when you need to request either a network or benefit exception.
• Transplant Prior Authorization/Organizational Determination Form Use for transplant services.