[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-286872-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-286872-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","prior-authorization-fax-sheet","Prior Authorization Fax Sheet","","This document serves as a standardized fax coversheet for medical professionals to request prior authorization from UMR. It requires essential patient information, including the name, date of birth, member ID, and group number, alongside the ordering physician's credentials and contact details. Additionally, the form facilitates the submission of clinical service details such as the date of service, specific ICD-10 diagnostic codes, and requested CPT codes with session frequencies. It also includes specific sections for PT, OT, ST, and ABA therapy services, requiring a summary of previous visits. The document emphasizes the confidentiality of proprietary business information and underscores the legal necessity to protect Protected Health Information (PHI) in compliance with HIPAA regulations. Proper completion and attachment of clinical records are mandatory to ensure efficient processing of the authorization request by the benefits department.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/prior-authorization-fax-sheet/286872/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/prior-authorization-fax-sheet/286872.png","ImageObject",442,249,{"name":42,"@type":43},"Eden","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-21","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":22},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What information must be provided for the patient in this form?","Question",{"text":62,"@type":63},"The form requires the patient's name, date of birth, ID number, and group number.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How should the requested CPT codes be documented?",{"text":67,"@type":63},"You should enter the 5-digit CPT code, the number of sessions desired, and the specific start and end dates for each requested service.",{"name":69,"@type":60,"acceptedAnswer":70},"What is the purpose of this document?",{"text":71,"@type":63},"This document is used to submit a prior authorization request for medical procedures or therapies to UMR, along with the necessary clinical records.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},286872,1790017481,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":22,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},1374391974468,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","PLEASE COMPLETE FORM AND ATTACH WITH CLINICAL RECORDS  \nPlease contact the benefit department via the phone number on the insureds medical ID card for benefits on the procedure you are inquiring on to determine if prior authorization is required. The benefit department would advise level of coverage or if care is non-covered within the plan the patient has.  \nTo: PRIOR AUTHORIZATION DEPT  \nFrom:    \nPatient name:   Patient’s DOB:   ID \\#   Group \\#   \nOrdering Physician:  Credentials:   Address:   City:  State: Zip:  Phone \\#:    \nFax:    \nFacility:    \nFacility address:   Facility phone\\# :    \nDATE OF SERVICE:    \nICD-10:    \nCPT CODE (5 digit code): please enter number of sessions desired for each CPT requested: CPT: (  ) x ( ) sessions starting date ( ) to ending date ( )  \nCPT: (  ) x ( ) sessions starting date ( ) to ending date ( )  \nCPT: (  ) x ( ) sessions starting date ( ) to ending date ( )  \nFOR PT/OT/ST/ABA  \nHow many visits has patient used?   Prior case \\# on file:    \nInformation included in this document is considered to be UMR’s confidential and/or proprietary business information. Consequently, this information may be used only by the person or entity to which it is addressed by UMR for a legitimate purpose. Such recipient shall be liable for using and protecting UMR’s proprietary business information from further disclosure or misuse. The report you have received may also contain protected health information (PHI) and must be handled according to applicable law, including but not limited to HIPAA. Individuals who misuse information may be subject to both civil and criminal penalties","cbCairDYgYDp3wda","https://ap.wps.com/l/cbCairDYgYDp3wda","pdf",136027,"English","# Patient and Provider Information\n## Service and Billing Details","[{\"question\":\"What information must be provided for the patient in this form?\",\"answer\":\"The form requires the patient's name, date of birth, ID number, and group number.\"},{\"question\":\"How should the requested CPT codes be documented?\",\"answer\":\"You should enter the 5-digit CPT code, the number of sessions desired, and the specific start and end dates for each requested service.\"},{\"question\":\"What is the purpose of this document?\",\"answer\":\"This document is used to submit a prior authorization request for medical procedures or therapies to UMR, along with the necessary clinical records.\"}]","Prior Authorization Fax Sheet | PDF",1789631639]