Medication Prior Authorization
Medical (General) Prior Authorization
Behavioral Health Prior Authorization

Please select the appropriate prior authorization request form below and submit to:

Quartz Behavioral Health Care Management

  • Fax (608) 471-4391

Submission instructions are included with all forms.

Initial Mental Health Request Form

AODA Initial Request Form

  • Do not use these forms to request PA for TMS. 
  • A prior authorization (PA) is only required for outpatients if the request is for services with an out-of-network provider.

Mental Health Treatment Extension Request

AODA Extension Request Form

  • Use these forms to request an extension of a previously approved request.

Transcranial Magnetic Stimulation (TMS) Request Form
  • This form is used without the Initial Mental Health Treatment Request 
Eating Disorder Supplemental Request Form
  • This form is used in addition to the Initial Mental Health Treatment Request or the Extension Mental Health Treatment Request form.

For self-funded participants, please login to MyPlanTools to access your patient's PA List.