Prior Authorization Fax Request Form printable pdf download

Prior Authorization Fax Request Form

Fax: 866-607-5975

Phone: 866-604-3267

Please complete all fields on the form referring to the list of services that require authorization at

. Submit all relevant clinical data such as progress notes, treatment rendered, tests, lab results,

and radiology reports to support the request for services. This will help us process your request without delay. Failure to

provide sufficient information will delay your request.

Date: ____________ Contact person: ____________________ Phone: ________________________

Fax: _______________________ HIPAA secure fax line? □ Yes □ No

Requesting Provider: ______________________________ TIN/NPI: ___________________________

Member Information

Member name: _________________ Member ID/JD#:__________________ Date of birth: __________

Member pregnant? □ Yes □ No Related to a motor vehicle accident or work-related injury? □ Yes □ No

Member have other insurance? □ Yes □ No If yes, Medicare □ Part A □ Part B

Other insurance name and policy #_________________________________________________

Type of Request

□ Routine □ Expedited/Urgent (Request must include a physician’s order stating that waiting for a decision

under a standard timeframe could endanger the member’s life, health, or ability to regain maximum

functionality or would cause serious pain.)

□ Inpatient □ Outpatient □ Home

Servicing Provider and Facility Information

Servicing provider: _________________________________ TIN/NPI:_________________________

Address: _______________________________________ Fax:______________________________

Date of service: ____________________________________ In network □ Out of network □

Servicing facility: ___________________________________ TIN/NPI:____________________

Address:___________________________________________ In network □ Out of network □

Will out of network provider accept Medicaid/Medicare default rate? □ Yes □ No

Clinical Information

Diagnoses:_______________________ ICD-10 codes: _______________________________

Required CPT/HCPCS Code(s): __________________________________________________

Miscellaneous and/or unlisted codes description required: ________________________________

Number of visits: ____________ Start date:______________ End date: ______________________

Frequency: ____________________DME Cost: $_________

Number of previous visits/service description/CPT/HCPCS codes?: __________________________

____________________________________________________________________________________

Confidentiality Notice: The documents in this correspondence may contain confidential health information that is privileged and

subject to state and federal privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA). This information is

intended for the sole use of the addressee named above. If you are not the intended recipient, you are hereby notified that reading,

disseminating, disclosing, distributing, copying, acting upon, or otherwise using the information contained in this correspondence is

strictly prohibited. If you received this information in error, please notify UnitedHealthcare to arrange for the return of the documents

to us or to verify their destruction.

UCS, C&S Prior Auth Fax Form_2015

Prior Authorization Fax Request Form