Prior Authorization Forms | Providers | Sentara Health Plans

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

Commercial Inpatient Authorization Requests

Inpatient Request Form - Commercial
PDF, 186 KBLast Updated: 04/04/2025
PDF, 186 KBLast Updated: 04/04/2025

Commercial Outpatient Authorization Requests

Outpatient Services Authorization Request - Commercial
PDF, 149 KBLast Updated: 04/07/2025
PDF, 149 KBLast Updated: 04/07/2025
Durable Medical Equipment (DME) Authorization Request - Commercial
PDF, 136 KBLast Updated: 04/04/2025
PDF, 136 KBLast Updated: 04/04/2025

Behavioral Health

ABA Authorization
PDF, 242 KBLast Updated: 05/29/2024
PDF, 242 KBLast Updated: 05/29/2024
Behavioral Health Discharge Summary
PDF, 96 KBLast Updated: 05/29/2024
PDF, 96 KBLast Updated: 05/29/2024
Behavioral Health Inpatient Authorization Request
PDF, 135 KBLast Updated: 05/29/2024
PDF, 135 KBLast Updated: 05/29/2024
Behavioral Health Outpatient Authorization Request
PDF, 109 KBLast Updated: 07/19/2024
PDF, 109 KBLast Updated: 07/19/2024
Electroconvulsive Therapy (ECT) Authorization Request
PDF, 169 KBLast Updated: 05/29/2024
PDF, 169 KBLast Updated: 05/29/2024
Transcranial Magnetic Stimulation (rTMS) Authorization Request Form
PDF, 270 KBLast Updated: 05/29/2024
PDF, 270 KBLast Updated: 05/29/2024

Radiology and Oncology

Chemotherapy and Supportive Care Commercial Medical 316
PDF, 309 KBLast Updated: 04/02/2025
PDF, 309 KBLast Updated: 04/02/2025
Chemotherapy and Supportive Care Medicaid Medical 316
PDF, 314 KBLast Updated: 04/02/2025
PDF, 314 KBLast Updated: 04/02/2025
Chemotherapy and Supportive Care Medicare Medical 316
PDF, 331 KBLast Updated: 03/25/2025
PDF, 331 KBLast Updated: 03/25/2025

Transitional Care Request

Transitioning Care to Sentara Health Plans
PDF, 171 KBLast Updated: 05/29/2024
PDF, 171 KBLast Updated: 05/29/2024