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Collects requesting provider details, member demographic and eligibility fields, pregnancy and accident or work-injury indicators, and other insurance/Medicare status. Captures request type (routine or expedited with required justification), care setting, servicing provider and facility network status, and detailed clinical support including diagnoses and required CPT/HCPCS codes, visit counts, service dates, and DME cost. Includes HIPAA confidentiality notice and contact information for questions.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/prior-authorization-form-fax-completed-form/283862/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/prior-authorization-form-fax-completed-form/283862.png","ImageObject",442,249,{"name":88,"@type":89},"Berry Peter","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Where should the completed prior authorization form be faxed?","Question",{"text":108,"@type":109},"Fax the completed form to 888-899-1681.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required to submit an expedited/urgent prior authorization request?",{"text":113,"@type":109},"Include a physician’s order stating that waiting for a decision under the standard timeframe could endanger the member’s life, health, ability to regain maximum functionality, or cause serious pain.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical documentation should be submitted to support the prior authorization request?",{"text":117,"@type":109},"Submit relevant clinical data such as progress notes, treatment rendered, tests, lab results, and radiology reports, along with diagnoses and required CPT/HCPCS codes.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283862,1790213743,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1374402524268,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Prior Authorization Form  \nFax completed form to: 888-899-1681  \nIf you have a prior authorization request, please complete all fields on this form for services that require prior authorization and fax the completed form to 888-899-1681. A complete list of services that require authorization is available [at UHCCommunityPlan.com](at UHCCommunityPlan.com) > Health Care Professionals > Maryland > Provider Information. Submit all relevant clinical data such as progress notes, treatment rendered, tests, lab results, and radiology reports to support the request for services. This will help us process your request without delay. If you have questions, please call Provider Services at 866-604-3267.  \nDate:   Contact person:   Phone:    \nFax:   HIPAA secure fax line? □ Yes □ No  \nRequesting Provider:   TIN/NPI:    \nMember Information  \nMember name:   Member ID\\#:  Date ofbirth:   Member pregnant? □ Yes □ No Related to a motor vehicle accident or work-related injury? □ Yes □ No Member have other insurance? □ Yes □ No If yes, Medicare □ Part A □ Part B  \nOther insurance name and policy \\#   \nType of Request  \n□ Routine □ Expedited/Urgent (Request must include a physician’s order stating that waiting for a decision under a standard timeframe could endanger the member’s life, health, or ability to regain maximum functionality or would cause serious pain.)  \n□ Inpatient □ Outpatient □ Home health  \nServicing Provider and Facility Information  \nServicing provider:   TIN/NPI:   Address:     Fax:   Date of service:   In network □ Out of network □ Servicing facility:   TIN/NPI:  Address:  In network □ Out of network □ Will out of network provider accept Medicaid/Medicare default rate? □ Yes □ No  \nClinical Information  \nDiagnoses:  ICD-10 codes:   \nRequired CPT/HCPCS Code(s):   Miscellaneous and/or unlisted codes description required:   Number of visits:   Start date:  End date:    \nFrequency:   DME Cost: $   \nNumber of previous visits/service description/CPT/HCPCS codes?:    \n___________________________________________________________________________________  \nConfidentiality Notice: The documents in this correspondence may contain confidential health information that is privileged and subject to state and federal privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA) . This information is intended for the sole use ofthe addressee named above. If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon, or otherwise using the information contained in this correspondence is strictly prohibited. If you received this information in error, please notify UnitedHealthcare to arrange for the return of the documents to us or to verify their destruction.","cbCaiuRd8GnXtQPy","https://ap.wps.com/l/cbCaiuRd8GnXtQPy","pdf",168729,"English","# Prior Authorization Form\n## Submission Instructions\n## Request and Member Information\n## Type of Request\n## Servicing Provider and Facility Information\n## Clinical Information\n## Confidentiality Notice","[{\"question\":\"Where should the completed prior authorization form be faxed?\",\"answer\":\"Fax the completed form to 888-899-1681.\"},{\"question\":\"What information is required to submit an expedited/urgent prior authorization request?\",\"answer\":\"Include a physician’s order stating that waiting for a decision under the standard timeframe could endanger the member’s life, health, ability to regain maximum functionality, or cause serious pain.\"},{\"question\":\"What clinical documentation should be submitted to support the prior authorization request?\",\"answer\":\"Submit relevant clinical data such as progress notes, treatment rendered, tests, lab results, and radiology reports, along with diagnoses and required CPT/HCPCS codes.\"}]","Prior Authorization Form - Fax Completed Form | PDF",1789621005]