Initial Authorization Request Form - Maine
Orthotic/ Prosthetic Devices Physical Therapy Occupational Therapy Phy sician Administered Drugs Chiropractic Services Methadone Treatment Clinic In -State Ambulance In -State Nursing Facility-Complex Care Ventilator Services 12. Urgent Requests – Enter reason here:
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Physical Therapy Request for Chronic Pain Form
mainecare.maine.govDepartment of Health and Human Services MaineCare Services Prior Authorization Unit, Physical/Occupational Therapies 11 State House Station Augusta, Maine 04333-0011
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