Pain Form Submission Portal
Use the forms below to submit a Request
This portal contains the prior authorization request forms for pain injections.
Select the appropriate form from the dropdown list provided below.
After you have download and opened the form, you should fill it out in its entirety and hit the submit button to securly send the information back.
For the best experience you should not open the form in your web browser and rely on the adobe acrobat reader. Alternativley you fax the completed form to 423.800.5302.
