Submit a Preauthorization Request

The requesting medical provider must submit the appropriate requested treatment and clinical notes. Type N/A for any information not applicable or available at time of request.
  • 1

    Form Status

  • 2

    submissions & attachments

  • Where you would like the confirmation email sent to print or store for your records (all submitted fields included)?
  • Attachments

    Please attach supporting clinical records to validate this request.
    PLEASE INCLUDE TDI Standard Prior Authorization Request Form for Health Care Services.

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CORPORATE OFFICE


P.O. Box 260287

Plano, TX 75026

Phone: 972.387.8297

Toll Free: 877.742.4477

Fax: 972.331.8184

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Houston, TX 77240

Phone: 713.339.1268

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Fax: 713.974.1539

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SAN ANTONIO OFFICE


Phone: 877.789.0041

Fax: 877.974.1962