Physical Preauthorization Request - Injury Management Organization

If you do not have a physical copy of the TDI Standard Prior Authorization Request Form for Health Care Services form already filled out, please click here to submit our full form online.

Submissions & Attachments
Patient Name*
First Last
Claim Number*
Employer*
Contact Email for Confirmation*

Where you would like the confirmation email sent to print or store for your records (all submitted fields included)?
Today's Date*
MM slash DD slash YYYY
Attachments

Please attach supporting clinical records to validate this request.
PLEASE INCLUDE TDI Standard Prior Authorization Request Form for Health Care Services.
Deliver records by
- I will attach all records to this form below - Please name files based on the patient's last name.
- I will fax all records to 713.974.1962
Additional comments