Prior Approval Application Form (STP) – FROM 01 APRIL 2017

Please note that some policies have their own prior approval form which must be completed instead of this form.  Policies with their own prior approval form include: Blepharoplasty & Ptosis, Botox, Ear Wax Removal, Carpal Tunnel, Dupuytren’s, Ectropion, Fertility, Hernia, Tonsillectomy and Varicose Veins.