Unitedhealthcare Prior Authorization Request Form - Elidel/protopic

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24 HOUR – URGENT
ELIDEL/PROTOPIC
PRIOR AUTHORIZATION REQUEST
Complete ENTIRE form and Fax to: 866-940-7328
Today‘s Date:
SECTION A - PATIENT INFORMATION
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
No
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:
SECTION C - MEDICAL INFORMATION
Medication:
Strength:
Dosing frequency:
Directions for use:
Diagnosis (Please be specific & provide as much information as possible):
ICD-10 CODE:
Is the requested medication intended to be applied topically to the face, axillae (armpit), or genital area for this
patient? Yes____ No____
Has the patient been previously treated with at least two topical corticosteroids which resulted in an inadequate
response? Yes____ No____
List medications tried and dates of therapy: ______________________________________________________________
____________________________________________________________________________________________________
Did the patient experience an intolerance/ adverse reactions, or has a documented contraindication, to treatment
with at least two topical corticosteroids? Yes____ No____
List medications tried and adverse reaction/intolerance: ___________________________________________________
____________________________________________________________________________________________________
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:

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