Medical Drugs Prior Authorization Form - United Healthcare Page 2

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Medical Drugs Prior Authorization Form
Administration Location (Check below):
Administration Method (Check below):
Physician’s Office
Oral
Infusion Center
Topical
Patient Home
Injection
Home Health Care
IV
Outpatient Hospital
Other:
Facilities: Long Term Care, Skilled
Nursing or Acute Rehabilitation
Other Location (Please
Specify):______________________
Diagnosis for Medication:
ICD-9/ Codes:
Relevant Medications tried and failed:
SERVICING PROVIDER INFORMATION
(If different than Requesting Provider Information)
Provider Name:
Provider Tax ID Number:
Provider Address:
Provider Fax Number:
Provider Phone Number:
Please attach relevant clinical information to this request.
Attestation: I attest the information provided is true and accurate to the best of my knowledge.
I understand that UnitedHealthcare may perform a routine audit and request the medical
information necessary to verify the accuracy of the information reported on this form.
Prescriber or Authorized Signature: _________________________Date: ______________
Confidentiality Notice: The documents accompanying this transmission contain confidential
health information that is privileged. If you are not the intended recipient, any disclosure,
copying distribution, or action taken in reliance on the content of these documents is prohibited.
If you have received this information in error, please notify the sender immediately by fax and
arrange for the return or destruction of the documents.
2
RX-PRIOR - 11/5/2014
PCA15024_20141211

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