Service Authorization are on hold until the end of the Federal Public Health Emergency.
Service Authorization Request Forms
Service authorizations are required for all services after participant state fiscal year limits have been exhausted. Providers can submit service authorizations either through an Online Portal or by completing a PDF and faxing to Optum. Providers are encouraged to use the forms used on this webpage as form versions may change.
Service Authorization Online Submissions
Service Authorization Fillable Forms
To submit Service Authorization forms via fax, please send to: 1-844-881-3753
- 1115 SUD Waiver Service Authorization (pdf)
- 1115 BH Waiver Service Authorization (pdf)
- Autism Services Service Authorization (SA) Request Form (pdf)
- Mental Health Physician Clinic (MHPC) Service Authorization (SA) Request Form (pdf)
- Psychological and Neuropsychological Testing Service Authorization (SA) Request
- State Plan Service Authorization (pdf)