Medical Prior Authorization Tracking Log PDF

Track every prior authorization request, insurer contact, and decision for medications, imaging, surgeries, and other services.

Patient name

Insurance company

Date of birth

Member ID

Requesting provider

Clinic / hospital

Authorizations

Track service requests, statuses, and follow-ups for medications, imaging, or procedures.

Authorization 1

Request date

Service type

CPT / code

Diagnosis code

Requesting provider

Status

Decision date

Authorization #

Follow-up date

Notes

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