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Indiana Standard PA Form for Health Care Services

Indiana's Department of Insurance publishes a standard form for requesting prior authorization of a health care service from an insurer, HMO or plan administrator. Clinicians meet it when a commercial plan requires approval for a procedure, therapy, home health, DME or an admission. The form gathers codes, setting and clinical documentation in six sections, and the issuer records any denial reason in Section VII.

Who completes it

The requesting physician or provider completes Sections I to VI: issuer, urgency, patient, providers, service codes and the clinical narrative. The issuer completes Section VII if it denies or partly denies the request; the patient completes nothing.

Submitting and payment

How to submit it
Mail or fax the form to the issuer, never to the Indiana Department of Insurance or the patient's employer. Issuers may offer an electronic version through their portal, and some pre-fill Section I with their contact details.

Good to know

  • Do not use it for appeals, eligibility or coverage checks, asking whether a service needs authorization, prescription drug requests, or referrals to out-of-network providers.
  • Request urgent review for a hospitalized patient, care after an emergency is stabilized, or an acute condition severe enough to risk serious deterioration while waiting.
  • If the requesting provider's signature is required, a signature stamp is not accepted. Enter 'Same' when the requesting and service provider are identical, or when the requester is the PCP.
  • The Department encourages, but does not require, issuers to accept the form, and some issuers ask for more information or their own additional forms.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization Request Form for Health Care Services for Use in Indiana

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can the Indiana standard prior authorization form be used for prescription drugs?

No. Its instructions exclude prescription drug prior authorization, along with appeals, eligibility and coverage checks, questions about whether authorization is needed, and referrals to out-of-network providers. It is meant for health care services such as procedures, therapy, home health, DME and admissions.

Do Indiana insurers have to accept the standard PA form?

The Indiana Department of Insurance encourages insurers, HMOs, administrators and others to accept it when their plan requires prior authorization, but acceptance is not mandated. Some issuers need more information or extra forms, so the instructions advise checking the issuer's website before sending.

Is the issuer's call about missing information a peer-to-peer review?

No. The contact line at the bottom lets an issuer call the requesting provider about information it needs to process the request. The instructions say this call is not the peer-to-peer discussion a utilization review agent offers before issuing an adverse determination.