| Assigned number | Title | Release date Sort ascending | Language | Available to order |
|---|---|---|---|---|
| F-11035A | Prior Authorization Dental Request Form (PA/DRF) Instructions (PDF) | 06/14/2024 | English | No |
| F-11035 | Prior Authorization Dental Request Form (PA/DRF) (PDF) | 06/14/2024 | English | No |
| F-11035 | Prior Authorization Dental Request Form (PA/DRF) (Word) | 06/14/2024 | English | No |
Last revised July 26, 2026