Pre-authorization Request Form

Pre-authorization Request Form

Complete the following form and submit the appropriate clinical information (clinical information can be submitted to preauthorization@fchn.com or faxed to (888) 272-3289). For questions call Medical Management department  (800) 808-0450.

Patient Information
Group Information
Subscriber Information
Requester Information
Facility/Vendor Information
Physician Information
Diagnosis Codes
Procedure Codes

Click here to submit clinical information via email.