Washington Prior Authorization Fax Request Form - Unitedhealthcare

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Washington Prior Authorization
Fax Request Form
Fax: 855-554-2152
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:____________________
Diagnostic Cytogenetics, Inc.
TIN: 91-1134800 / NPI: 1104899376
□
□
Address:___________________________________________ In network
Out of network
1525 13th Ave, Seattle, WA 98122
□
□
Will out of network provider accept Medicaid/Medicare default rate?
Yes
No
Clinical Information
Diagnoses:
ICD-9 codes:
_____________________
________________________________________
Required CPT/HCPCS Code(s): __________________________________________________
88377
Miscellaneous and/or unlisted codes description required: ________________________________
In situ hybridization, multiplex probe staining
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.
UHC2335a_20121213

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