---
title: Pre-authorization request form
description: The Pre-authorization request form includes the details of the pre-authorization request provided by a payer for a patient.
locale: en-US
canonical_url: https://www.servicenow.com/docs/r/australia/healthcare-life-sciences/healthcare-and-life-sciences-service-management-core/hcls-pre-auth-form.html
release: australia
product: Healthcare and Life Sciences Service Management Core
classification: healthcare-and-life-sciences-service-management-core
topic_type: reference
last_updated: "2026-03-12"
reading_time_minutes: 1
breadcrumb: [Reference, Healthcare and Life Sciences Service Management Core, Healthcare and Life Sciences Service Management, Healthcare and Life Sciences]
---

# Pre-authorization request form

The Pre-authorization request form includes the details of the pre-authorization request provided by a payer for a patient.

<table id="table_ut3_b5r_crb"><thead><tr><th>

Field

</th><th>

Description

</th></tr></thead><tbody><tr><td>

Primary pre-auth number

</td><td>

Primary pre-authorization number generated by the payer organization.

</td></tr><tr><td>

Secondary pre-auth number

</td><td>

Secondary pre-authorization number generated by the payer organization.

</td></tr><tr><td>

Primary diagnosis

</td><td>

Main condition in a patient submitted by the practitioner as the reason for the healthcare service requested in the pre-authorization request.

</td></tr><tr><td>

Medication prescription

</td><td>

Medication prescription for which the pre-authorization request is created for the patient.

</td></tr><tr><td>

Status

</td><td>

Approval status of the pre-authorization request.

</td></tr><tr><td>

Date approved

</td><td>

Date when the pre-authorization request was approved by the payer organization.

</td></tr><tr><td>

Valid from

</td><td>

Start date of the pre-authorization request validity period.

</td></tr><tr><td>

Valid until

</td><td>

End date of the pre-authorization request validity period.

</td></tr><tr><td>

Notes

</td><td>

Instructions or explanation for the pre-authorization request.

</td></tr></tbody>
</table>**Parent Topic:**[Healthcare and Life Sciences Service Management Core reference](https://raw.githubusercontent.com/ServiceNow/ServiceNowDocs/australia/markdown/australia/healthcare-life-sciences/healthcare-and-life-sciences-service-management-core/hcls-serv-mgmt-core-reference.md)