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, 205 KB Last Updated: 10/09/2026
PDF, 205 KB Last Updated: 10/09/2026
Post Acute Care Clinical Information Requirements - Commercial
PDF, 448 KB Last Updated: 10/09/2026
PDF, 448 KB Last Updated: 10/09/2026

Commercial Outpatient Authorization Requests

Outpatient Services Authorization Request - Commercial
PDF, 163 KB Last Updated: 10/09/2026
PDF, 163 KB Last Updated: 10/09/2026
Durable Medical Equipment (DME) Authorization Request - Commercial
PDF, 151 KB Last Updated: 10/09/2026
PDF, 151 KB Last Updated: 10/09/2026

Radiology and Oncology

Chemotherapy and Supportive Care Commercial Medical 316
PDF, 351 KB Last Updated: 10/09/2026
PDF, 351 KB Last Updated: 10/09/2026
Chemotherapy and Supportive Care Medicaid Medical 316
PDF, 354 KB Last Updated: 10/09/2026
PDF, 354 KB Last Updated: 10/09/2026

Transplant-Related Travel

Transplant Travel Prior Authorization Form
PDF, 181 KB Last Updated: 10/09/2026
PDF, 181 KB Last Updated: 10/09/2026

Transitioning Care to Sentara Health Plans

Transitioning Care to Sentara Health Plans
PDF, 171 KB Last Updated: 10/09/2026
PDF, 171 KB Last Updated: 10/09/2026