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Collects member and prescriber details, including patient demographics, authorized representative information, insurance identifiers, and medication and dispensing data such as dose, frequency, quantity, administration route, and therapy timeline. Includes sections for prior therapy history, related diagnoses with ICD-10 coding, required clinical information, attachments, and prescriber attestation. 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Attach any additional documentation that is important for the review , e.g. chart notes or lab data, to support the prior authorization or step-therapy exception   request. Information contained in this form is Protected Health Information under HIPAA.\u003Cbr>*Note: Please submit your request online using our Prior Authorization and Notification Tool on Link. You can access the tool at [w ww.UHCprovider.com/paan](w ww.UHCprovider.com/paan. You may)[. You may](w ww.UHCprovider.com/paan. You may) also initiate your request by phone by calling the number on the member’s ID card. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  | Last Name: |  |  |  |  | MI: |  |  | Phone Number: |  |  |  |  |\n| Address: |  |  |  |  | City: |  |  |  |  |  |  | State: |  |  | Zip Code: |\n| Date of Birth: |  Male\u003Cbr> Female |  |  | Circle unit of measure\u003Cbr>Height (in/cm): Weight (lb/kg):  |  |  |  |  | Allergies: |  |  |  |  |  |  |\n| Patient’s Authorized Representative (if applicable): |  |  |  |  |  |  | Authorized Representative Phone Number: |  |  |  |  |  |  |  |  |\n| Insurance Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Primary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Secondary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Prescribe r Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  |  | Last Name: |  |  |  |  |  | Specialty: |  |  |  |  |  |\n| Address: |  |  |  |  |  | City: |  |  |  |  |  | State: |  | Zip Code: |  |\n| Requestor (if different than prescriber): |  |  |  |  |  |  | Office Contact Person: |  |  |  |  |  |  |  |  |\n| NPI Number (individual): |  |  |  |  |  |  | Phone Number: |  |  |  |  |  |  |  |  |\n| DEA Number (if required): |  |  |  |  |  |  | Fax Number (in HIPAA compliant area): |  |  |  |  |  |  |  |  |\n| Email Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication / Medical and Dispensing Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  New Therapy  Renew al  Step Therapy Exception Request\u003Cbr>If Renew al: Date Therapy Initiated: Duration of Therapy (specific dates): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| How did the patient receive the medication?\u003Cbr> Paid under Insurance Name:  Prior Auth Number (if know n):   Other (explain): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Dose/Strength: |  | Frequency: |  |  |  |  | Length of Therapy/\\#Refills: |  |  |  |  |  | Quantity: |  |  |\n| Administration:\u003Cbr> Oral/SL  Topical  Injection  IV  Other: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Administration Location:  Patient’s Home  Long Term Care\u003Cbr> Physician’s Office  Home Care Agency  Other (explain): \u003Cbr> Ambulatory Infusion Center  Outpatient Hospital Care   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nPRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM  \n\n| Patient Name: | ID\\#: |\n| --- | --- |\n\nInstructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review , e.g. chart notes or lab data, to support the prior authorization or step therapy exception request.  \n\n| \u003Cbr>1. Has the patient tried any other medications for this condition? YES (if yes, complete below) NO |  |  |  |\n| --- | --- | --- | --- |\n|  | Medication/Therapy\u003Cbr>(Specify Drug Name and Dosage) | Duration of T","cbCaijAVL62wkWPx","https://ap.wps.com/l/cbCaijAVL62wkWPx","pdf",97880,"English","# Patient Information\n# Insurance Information\n# Prescriber Information\n# Medication / Medical and Dispensing Information\n# Prior Therapy and Diagnoses\n# Required Clinical Information\n# Attestation\n# Plan/Insurer Use Only","[{\"question\":\"What information is needed for the patient section of this form?\",\"answer\":\"The form requests the patient’s name, identification number, date of birth, sex, phone number, address, allergies, and (if applicable) the patient’s authorized representative details.\"},{\"question\":\"How does the form capture medication and therapy details?\",\"answer\":\"It collects medication name, whether it is a new therapy, renewal, or step-therapy exception request, dose/strength, frequency, therapy duration, quantity, route of administration, and administration location.\"},{\"question\":\"What clinical documentation should be attached for review?\",\"answer\":\"Attach any additional documentation important for review, such as chart notes or lab data, and provide required clinical information including symptoms, lab results with dates where needed, and relevant justification for initial or ongoing therapy or increased dose.\"}]","Prescription Drug Prior Authorization or Step Therapy Exception Request Form - CA | PDF",1789623446]