Standard Prior Authorization Request Form - United Healthcare

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Standard Prior Authorization Request Form
Section I — Please fax your request to 866-756-9733.
Date and Time Submitted: ________________________________________________ a.m. / p.m. ET/MT/CT/PT
Section II — General Information
Review Type: Routine
Urgent
Clinical reason for urgency
Request Type:
Initial Request
Extension/Renewal/Amendment
(Prev. Auth. #: ________________________________________
)
Section III — Patient Information
Sex: □ Male □ Female
Name
Patient Preferred Phone #
DOB

Subscriber Name (if different)
Member ID #
Group #
Section IV ― Provider Information
Requesting Provider or Facility Name
Service Provider or Facility Name
NPI # or Tax ID #
Specialty
NPI # or Tax ID #
Specialty
Phone
Fax
Phone
Fax
Address
Address
Name of Primary Care Provider
Phone
Fax
Section V ― Services Requested (with CPT, CDT, or HCPCS Code) and Supporting Diagnoses (with ICD-10 Code)
Start
End
Diagnosis Description
Planned Service or Procedure
Code(s)
Code(s)
Date
Date
□ Inpatient □ Outpatient □ Provider Office □ Observation □ Home □ Day Surgery □ Other (specify)
□ Physical Therapy □ Occupational Therapy □ Speech Therapy □ Cardiac Rehab □ Mental Health/Substance Abuse
Number of sessions
Duration
Frequency
Other
□ Home Health
MD signed order must be attached to this request. Please also attach the nursing assessment.
Number of visits requested
Duration
Frequency
Other
□ Durable Medical Equipment MD signed order must be attached to this request.
Equipment/supplies (Include any HCPCS Codes)
Duration
Section VI ― Clinical Documentation
Please provide a brief explanation of medical necessity for service(s) and attach supporting clinical documentation with this request.
Please provide contact information, in case we need more information:
Name: ________ Phone ________ (ext. _________) email __________________________________________
Preferred method of contact is: □ phone □ email
Section VII ― Reason for Denial or Partial Denial
Doc#: PCA-1-001933-05122016-06242016

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