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Submit a treatment authorisation request

Please note

If you are a hospital, you can securely search for and request pre-authorised treatment on Healthcode.

If you do not have access to this, please complete the form below.

Provider name

This is the practitioner, hospital or clinic providing the service

Email address

Contact name

Patient's plan number

Patient's name

Patient's postcode

Enter address manually

Select address

First line

First line is required

Second line

Third line

Town/City

Town/City is required

County

Postcode

Postcode is required

Claim number

Provider Type

Individual practitioner Group practice or therapy clinic Hospital/Outpatient clinic

Setting

Inpatient Outpatient Day patient

Hospital name

Where the treatment will take place

Treatment start date

Treatment end date

Proposed procedure codes or description

If supplying multiple procedure codes, please separate with a comma

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