Topical Androgens Prior Authorization Request Form (Page 3 of 3) in pdf

Topical Androgens Prior Authorization Request Form Page 3

Topical Androgens Prior Authorization Request Form (Page 3 of 3)

Prescriber attestation:

Does the prescriber attest that the information provided is true and accurate to the best of their knowledge and understand that

UnitedHealthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the information

provided?  Yes  No

Prescriber’s signature: ______________________________

Date: _________________

* May not apply to all plans

**This product may require prior authorization

Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to

this review?

_________________________________________________________________________________________________________________

Please note:

This request may be denied unless all required information is received within established timelines.

This request may be denied unless all required information is received.

For urgent or expedited requests please call 1-800-711-4555.

This form may be used for non-urgent requests and faxed to 1-800-527-0531.

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider

named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose

PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information

in this document is against the law. If you are not the intended recipient, please notify the sender immediately.

Office use only: TopicalAndrogens_UHCE&I_2016Dec-W.doc