Medical Drugs Prior Authorization Form - United Healthcare

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Medical Drugs Prior Authorization Form
Please use this form when requesting prior authorization for medical drugs. Thank you.
FAX:
866-756-9733
DATE: ______________________
ONLINE:
PATIENT INFORMATION
Member Name:
Member identification (ID) Number:
Subscribe Number:
Member Address:
Member Date of Birth:
Member Phone:
Authorized Representative:
Authorized Representative Phone:
Primary Insurance Name with ID Number:
Gender:
Height/Weight:
Allergies:
REQUESTING PROVIDER INFORMATION
Provider Name:
Provider NPI Number:
Provider Address:
Provider Phone:
Provider Tax ID Number:
Provider Fax:
Provider DEA (if required):
Office Contact Person:
Provider Specialty:
Office Contact Fax:
Office Contact Phone:
DRUG INFORMATION
Medication Name and Strength:
Directions for Use:
New Therapy/Renewal:
Duration:
Quantity:
HCPC/CPT Codes:
1
RX-PRIOR - 11/5/2014
PCA15024_20141211

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