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Prior Authorization Request - Providence Health Plan

Prior Authorization Request **Chart Notes Required** Please fax to: 503-574-6464 or 800-989-7479 | Questions please call: 503-574-6400 or 800-638-0449 IMPORTANT NOTICE: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately and destroy the related message.

Request must include supporting documentation to substantiate an expedited review. Explanation Required: In-Network Benefits: Request must include supporting documentation to substantiate why services cannot be provided by an in-network provider/facility.

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