This government document is issued by Division of Insurance (DOI) for use in Massachusetts
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https://www.mass.gov/doc/massachusetts-standard-form-for-medication-prior-authorization-request/download?_gl=1*1ycxzop*_ga*MTY2NTg2Nzk5LjE3MzE2NzIwODE.*_ga_MCLPEGW7WM*MTczMTY3MjA5NS4xLjEuMTczMTY3NDMwNy4wLjAuMA..&_ga=2.6840436.790269867.1731672081-166586799.1731672081