Fillable Unitedhealthcare Prior Authorization Request Form

Unitedhealthcare Prior Authorization Request Form - Daliresp

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24 HOUR – URGENT

DALIRESP

PRIOR AUTHORIZATION REQUEST FORM

Complete ENTIRE form and Fax to: 866-940-7328

SECTION A - PATIENT INFORMATION

Today‘s Date:

First Name:

Last Name:

Member ID #:

Address:

City:

State:

Zip:

Phone:

DOB:

Allergies:

Primary Insurance:

Policy #:

Group #:

□

Is the requested medication NEW

or a CONTINUATION of THERAPY

? If so, start date:_____________

□

Is this patient currently hospitalized?

Yes

SECTION B - PHYSICIAN INFORMATION

First Name:

Last Name:

M.D./D.O.

Address:

City:

State:

Zip:

Phone:

Fax:

NPI #:

Specialty:

Office Contact Name / Fax Attention to:

Medication:

Strength:

Directions for use:

ICD 10 Code:

Diagnosis (Please be specific & provide as much information as possible):

Does the patient have a diagnosis of severe COPD?

YES or NO (Circle Response)

Enter patient’s FEV

or FEV

/FVC: ____________________ (Must include FEV

or FEV

/FVC for request to be reviewed)

__________________________

Is the patient’s COPD associated with chronic bronchitis, emphysema, or both?

Does the patient currently smoke or has a history of smoking? YES or NO (Circle Response)

Has the patient had a COPD exacerbation in the last year?

YES or NO (Circle Response)

Date and description of exacerbation: ___________________________________________________________________

Drug Class (Examples)

Has the Patient

Dates of Trial

Outcome

tried?

Inhaled anticholinergic (e.g.

ipratropium, Combivent, Spiriva)

Long acting beta agonist (e.g.

Serevent, Foradil, Brovana)

Short acting beta2 agonist (e.g.

Ventolin HFA, Proventil HFA,

ProAir)

Inhaled Corticosteroid (e.g. Flovent,

Qvar, Asmanex, Pulmicort)

FOR CONTINUATION OF THERAPY: Has documentation been submitted showing the clinical benefit of Daliresp

therapy? YES or NO (Circle Response) Describe benefit of therapy: ______________________________________

FOR REQUESTS FOR DOSES > 500 MCG DAILY: Is there a reason why a greater quantity of medication is required

to treat the patient’s condition? YES or NO (Circle Response) If yes explain: ________________________________

: ________________________

_______________

Physician Signature

Date:

Confidentiality Notice: This transmission contains confidential information belonging to the sender and UnitedHealthcare. This information is intended only for

the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action involving the contents

of this document is prohibited. If you have received this telecopy in error, please notify the sender immediately.

Phone: 800-310-6826

Fax: 866-940-7328

Website:

Created 4/5/12 sb