Highmark Outpatient Authorization Form

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If You Are Requesting A Drug That Requires A Prior Authorization Or Step Therapy, Please Complete The Drug Specific Prior.

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888.236.6321 Or 800.670.4862 (Delaware) Inpatient:

Complete and fax all requested information below including any supporting. Web outpatient therapy services prior authorization request form use this form for all physical, occupational, speech, and feeding therapies, pulmonary and cardiac. Web highmark blue shield medical management and policy department outpatient authorization request form submission instructions: Web on this page, you will find some recommended forms that providers may use when communicating with highmark, its members or other providers in the network.