Provider Forms

Please use the forms in the tabs below. Scroll down to learn more about our EPO referral process.

Our new Utilization Management (UM) partner offers different forms for each type of Prior Authorization you may request in order to get the most specific and efficient information. If your patient’s service is not listed, you may use the General Medical Prior Authorization Form listed below.

Please submit Drug Specific forms when applicable to avoid delayed or denied authorization requests. 

Please submit completed prescription authorization requests via phone by calling 1.800.711.4555, electronically through .

If you cannot find the prior authorization form you are looking for by visiting OptumRx’s website, please complete the general prescriptions form here.

NOTE: When submitting an authorization request, it is important to use Drug Specific forms when applicable. Please use the most up-to-date forms on OptumRx’s website and be sure to include all of the relevant information. If a submitted request is missing information the request(s) can be delayed or denied due to lack of information.  Please check for the drug specific form because the use of out dated  or general forms may not contain all required elements and could result in a delay or denial of the authorization request. 

If there are not any in-network providers that can provide a medically necessary service, in-network providers may submit a written referral for a member to see an out-of-network provider. The referral request will be reviewed by CGHC.

Please note, referrals are only considered in rare circumstances and are generally NOT necessary for the following services:

  • Emergency Care
  • Urgent Care
  • Maternity care for new members in 3rd trimester of pregnancy (prior authorization is required)
  • Full-time students enrolled in Institutes of Higher Learning seeking behavioral health or substance abuse disorder treatment outside of CGHC’s services area but within the state of Wisconsin.

* Please note follow-up care is not covered at out-of-network facilities.

Did you know?


Because all Common Ground Healthcare Cooperative plans have an Exclusive Provider Organization (EPO) network, we offer almost any type of care that members will need, right within our network! For the few circumstances where our network providers cannot serve a members’ needs, we have an EPO referral process that providers can initiate to get approval for a member to go to an out-of-network provider. Learn more in our EPO frequently asked questions, linked below!