USFHP Prior Authorization

Prior Authorization: US Family Health Plan

To complete a prior authorization request for US Family Health Plan members, complete the form below with the following instructions.

US Family Health Plan Prior Authorization Form (PDF)
US Family Health Plan Prior Authorization Form Instructions (PDF)

PCP Referral to Specialist

Initial INN specialist office visit does not require PCP referral but any subsequent INN specialist office visits require PCP referral. All OON specialist visits required PCP referral & USFHP approval. Complete the following sections:

Date of Request
Level of Service
Member Information
Provider Information
Primary Care Physician section
Specialist Information
Office Visit Information
Request for Other Services, if applicable
Diagnosis/Procedure Information
To Be Completed by Requesting Physician
Physician Signature and Date

PCP Referral for Services

Complete the following sections:
Date of Request
Level of Service
Member Information
Provider Information, Primary Care Physician section
Request for Other Services, if applicable
Diagnosis/Procedure Information
To Be Completed by Requesting Physician
Physician Signature and Date

Specialist Request for Additional Visits or Services

Complete the following sections:
Date of Request
Level of Service
Member Information Requesting Specialist
Office Visit Information
Request for Other Services, if applicable
Diagnosis/Procedure Information
To Be Completed by Requesting Physician
Physician Signature and Date

All referrals and request for additional visits or services required clinical and completed referral/authorization form.