Prescriber Data Collection Form
This form is intended only for prescribers and providers who have received a request for clinical information as part of a prior authorization review. If you are not a prescriber responding to a specific request, this form is not for you.
Who Receives This Form
When a prior authorization requires additional clinical data, the requesting health plan sends a letter to the prescribing provider. That letter contains a unique link to this form. The link is specific to the patient and the request — it cannot be used for any other case.
Accessing the Form
Open the unique link from your letter in a web browser. You do not need to create an account or log in. The form loads a secure page titled Clinical Data Collection Form.
Step 1: Identity Verification
The first screen asks you to verify your identity before you can access the patient’s request:
- Enter the Patient Date of Birth using the date field.
- Enter Your NPI Number (your 10-digit National Provider Identifier).
- Select Verify Identity.
If the date of birth or NPI does not match what is on file, an error message will appear. Double-check the values on your letter and try again.
Step 2: Choose How to Provide Clinical Data
After verification succeeds, you will see the patient’s name and reference code, and you will be asked how you would like to submit the clinical information:
- Fill out the form — Enter demographics, observations, medications, diagnoses, and procedures manually in the online form.
- Upload a progress note — Upload a clinical document (PDF, Word, or an image); the system will automatically extract the relevant data and show you a review screen before submission.
Select the option that works best for you.
Filling Out the Form
If you choose Fill out the form, a structured form opens with sections for the clinical information requested. Complete the required fields and select Submit when finished.
Uploading a Progress Note
If you choose Upload progress note:
- Select Choose file (PDF, Word, images) and pick your document. Files up to 50 MB are supported.
- The system processes the document — this may take a moment. A progress indicator will display while processing is underway.
- Once extraction is complete, a review screen appears with the data pulled from your document pre-filled into the form. Review each field and correct anything that was not extracted accurately.
- Select Submit to send the reviewed data.
If there is a problem processing your file, you will see an error message with options to Back (return to the upload step) or Try again.
What Happens After Submission
Once you submit the form, you will see a confirmation message. The clinical data is sent directly to the reviewer handling the prior authorization. No further action is needed from you for this step.
If the authorization decision requires a follow-up (for example, if the request is denied), you may receive another letter with options to provide additional information or submit an appeal.
Current Authorization Status
Depending on the current state of the authorization, the form may display one of the following notices instead of the data entry screens:
| Status shown | What it means |
|---|---|
| Authorization Approved | This case has already been approved. No further data is needed. |
| Authorization Not Approved | The authorization was not approved. You will see options to provide additional clinical data or submit a formal appeal (if available). |
| Appeal Under Review | An appeal is currently being reviewed. You will be notified of the outcome. |
| Appeal Not Approved | The appeal was not approved. You may have options to provide additional clinical data or submit an external appeal (if available). |