Epidural Steroid Injections

We have created a printable form for staff members to print and share with physicians to pre-fill before starting the authorization request in the Cohere portal. Click here to download and print the clinical questions for ESI requests.


The questions in these documents are for reference only. PLEASE DO NOT FAX ANY OF THESE FORMSThese questions are designed to capture key information about the patient's specific clinical situation based on the diagnosis and services requested for approval. Answering these clinical assessment questions increases our ability to issue an auto-approval, which ultimately saves you time.

*Note that these questions are subject to change at any time without notice.*

*Last updated on August 16, 2022*


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