Prior Authorization


Complete the Prior Authorization Form (below) and fax or mail it to Gainwell Technologies (see address below). Be sure to include supporting documentation for review.

Prior Authorization Form 

Prior Authorization Instructions 

There can be multiple line items on a Prior Authorization Form but only one procedural code (PROC) or revenue code (REV) per line.


Completed forms can be faxed or mailed to:

Fax Number:  401-784-3892  (up to a maximum of 15 pages)

Mail to:             Gainwell Technologies- Prior Authorization

                           P.O. Box 2010

                           Warwick, RI 02887-2010

Certain programs have specific guidelines and forms to obtain prior authorization. See the links below for more information on these programs or services:

Durable Medical Equipment (DME)



Radiology Prior Authorization