Complete before your appointment and give to the staff handling authorization. Your organized information helps your provider submit a stronger, more complete request.
Worksheet · Print FriendlyPrior AuthorizationFree - No Email Required
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Prior Treatments Tried — Critical for Step Therapy
This section is the most important part. Insurance companies routinely deny requests because prior treatment history is missing. List every medication, therapy, or intervention already tried for this condition.
Treatment / Medication
Approx. Dates
Dose / Duration
Outcome
Provider
Relevant Testing or Outside Records
Test / Record Type
Approx. Date
Where Performed
Key Finding or Result
Additional Notes for Provider
Notes
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