Prior Authorization Forms

Form	Description	Last Revision Date
	Prior Authorization Checklist	June 2019
	Radiology Codes	Sept. 2006
	Independent Therapy Request Form	June 2018
	Obstetric Notification Form	Dec. 2009
MAP 5	EPSDT Dental Evaluation Form	March 2008
MAP 9	Prior Authorization for Health Services Instructions
July 2010
MAP 9A	Orthodonitc Services Agreement
June 2005
MAP 130	PA Fax Form	Sept. 2011
	Instructions for PA Fax
MAP 249	MAP 249 PDN Clinical Review
April 2014
MAP 306	Temporomandibular Joint (TMJ) Assessment
June 2005
MAP 396	Orthodontic Evaluation
June 2005
MAP 414	Application for Approval of Nurse Aide Training Program
June 2005
MAP 556	Orthodontic Referral
June 2005
MAP 559	Six Month Orthodontic Progress
June 2005
MAP 569	Psychiatric Preadmission Review of Elective Admissions
June 2005
MAP 570	Certification of Need for Inpatient Psychiatric Svcs for Individuals under Age 21
June 2005
MAP 575	Request for Reconsideration of Resources Utilization Group Audit Determination
June 2005
Map 576	Nurse Aide Training Expense Report and Authorization for Payment Instructions
July 2012
MAP 650	Home Health Fax Form 2009
Nov. 2008
MAP 700	Orthodontic Final Case Submission
June 2005
MAP 703	Request for Reconsideration Ancillary Therapy Billing
March 2014
MAP 726A	Nursing Facility Request for Admission
Sept. 2003
MAP 1000	Certificate of Medical Necessity - Durable Medical Equipment
July 2010
MAP 1000B	Certificate of Medical Necessity - Metabolic Formulas & Foods
July 2010