Prior Approval

Prior approval (PA) is required for many DHB services. The preferred method to submit PA requests is online via the NCTracks Provider Portal.

However, providers can also submit some paper forms via mail or fax. The links below reference the latest PA forms for submission to NCTracks. This list is the definitive source for DHB PA forms.

For a list of services that require PA, see the DHB policy specific to the services to be rendered.

For pharmacy PAs, refer to the Pharmacy Services page.

For additional information about how PA works in NCTracks, see the Prior Approval Fact Sheet on the Fact Sheet page of the Provider Portal.


Prior Approval Requests

The recommended method for submitting a PA request is to key it directly into the secure Provider Portal. If you must mail or fax a PA request, use the form below that pertains to the service being requested. See the DHB Clinical Coverage Policy Website for additional information. The below forms must be sent as the top page with any attachments behind it.

Prior Approval Attachments

The below forms should be sent in to accompany a PA request. These forms will NOT create a PA request. They must be sent in with one of the forms listed above. If not, your PA request may be delayed or not received at all.

School Reimbursement Form (DHB-3514) (replaced PDN Verification of School Nursing Form (DMA-3171))*

*Note: Providers are instructed to use the attachments in the current PDN 3G-2 Clinical Policy for Beneficiaries under 21 for each form (pages 25-35) until the 3G-2 policy is amended, at which time both policies will use the new forms located on the PDN webpage.

When either of the following forms are used, they should be uploaded as attachments to the PA request that has been keyed into the secure NCTracks Provider Portal. Neither of these forms can be used to create a PA request.

Long Term Care FL2 Form (372-124)



Prior Approval Forms for Pharmacy

Pharmacy Services Drug Request Forms page