✦ PA Submission

Submit a prior auth. We handle the rest.

Fill out the case details below. You'll be redirected to a secure Stripe checkout to complete payment. Our nurse-led team picks it up immediately after confirmation.

Practice & Contact

Practice Name *

Contact Email *

Contact Phone

Patient Identifiers

Patient Initials No full name required — initials for case tracking only.

Patient DOB

Authorization Details

Insurance Payer *

CPT Code(s) Requested * Separate multiple codes with commas.

Service Type * Tier is auto-selected based on service type. You can override below.

Tier Override (optional)

Urgency

Standard Target turnaround <4hr for Simple/Standard, <8hr for Complex. Included 🚨 Same-Day Rush Priority queue. Team begins within 2 hours. +$25

Total Due at Checkout —

Clinical Context

Clinical Notes / Supporting Context

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