---
sourceDocument: Yokohama Healthcare and Life Sciences
sourceDocumentLink: https://servicenow-prod.fluidtopics.net/r/yokohama/healthcare-life-sciences

 Release :

    - yokohama

ft:locale :

    - en-US

ft:publication_title :

    - Yokohama Healthcare and Life Sciences

ft:clusterId :

    - hcls

bundleId :

    - hcls

workflow :

    - Customer and Industry


---

# Pre-authorization request form

# Pre-authorization request form {#ariaid-title1}

Release version: Yokohama  
Updated January 30, 2025  
![](https://www.servicenow.com/docs/portal-asset/ico-clock) 1 minute to read  
The Pre-authorization request form includes the details of the pre-authorization
request provided by a payer for a patient.
{#hcls-pre-auth-form__table_ut3_b5r_crb__entry__2}

| Field | Description |
|-|-|
| Primary pre-auth number | Primary pre-authorization number generated by the payer organization. |
| Secondary pre-auth number | Secondary pre-authorization number generated by the payer organization. |
| Primary diagnosis | Main condition in a patient submitted by the practitioner as the reason for the healthcare service requested in the pre-authorization request. |
| Medication prescription | Medication prescription for which the pre-authorization request is created for the patient. |
| Status | Approval status of the pre-authorization request. |
| Date approved | Date when the pre-authorization request was approved by the payer organization. |
| Valid from | Start date of the pre-authorization request validity period. |
| Valid until | End date of the pre-authorization request validity period. |
| Notes | Instructions or explanation for the pre-authorization request. |
[Table 1. Pre-authorization request form fields]

{#hcls-pre-auth-form__table_ut3_b5r_crb}