Pre-Authorization Request Form

Please call directly with any questions 402-484-4801 or fax to 402-484-2590

Patient Name*
First Last
Date of Birth*
Insurance Company*
Member ID*
Name of Authorization Requester:*
First Last
Phone Number of the Authorization Requester:*
Email of the Authorization Requester:*
Fax Number of the Authorization Requester:*
Procedure:*
ICD-10:*
Urgency (choose one)*
Signs/Symptoms/Clinical Indications:*
Ordering Provider*
First Last
Prior Imaging*
- Yes
- No
If yes, location:
Conservative therapies:*
- Yes
- No
If yes, note frequency and duration. Be as specific as possible.
Is this request related to an injury?*
- Yes
- No
Date of Injury
MM slash DD slash YYYY
Please attach all supporting documents (clinical notes, labs, order, etc.) (jpg, png, pdf)
Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 300 MB.
Please attach all medical insurance cards (jpg, png, pdf)
Drop files here or

Accepted file types: jpg, png, pdf, docx, doc, Max. file size: 300 MB.

Next steps:

Once all documentation has been submitted and the preauthorization process has been completed, our scheduling department will reach out and schedule the patient for their appointment.