[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283990-105":53,"doc-detail-283990-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","prior-authorization-form-medical-information","Prior Authorization Form - Medical Information","","Structured prior authorization form for requesting medical services, including standard vs. urgent review selection and the required supporting documentation. Captures patient identity and demographics, ordering and rendering physician/clinic details, requested procedure and setting, and required HCPCS/CPT/CDT codes with medical reasoning. Includes fields for other services, prescription drug diagnosis and dosing information, current treatment status, and prior therapy discontinuation dates. Ends with provider attestation and plan-only authorization fields.",{"@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-medical-information/283990/",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-medical-information/283990.png","ImageObject",442,249,{"name":88,"@type":89},"Logic","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-03","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":45},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required for the priority section of this form?","Question",{"text":108,"@type":109},"The form requires selection of standard or date of service, and an urgent certification statement indicating that applying the standard review timeframe may jeopardize the member’s life or health.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which details must be provided for patient information?",{"text":113,"@type":109},"It collects the patient’s first and last name, MI, date of birth, gender, height and weight, address and city/state/ZIP, phone, health plan ID number, and group number.",{"name":115,"@type":106,"acceptedAnswer":116},"What must be included for prescription drug requests?",{"text":117,"@type":109},"The form requires diagnosis name and code, the medication requested, strength, dosing schedule including therapy length, quantity per month or quantity limits, whether the patient is currently on the requested medication (and start date if yes), and medical reasons for selecting it over alternatives.","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},283990,1791690859,{"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":45,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"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":9},1099513958762,"https://ap-avatar.wpscdn.com/avatar/1000023916a998db790?x-image-process=image/resize,m_fixed,w_180,h_180&k=1784791008015729253","All of the applicable information and documentation is required. Incomplete forms will be returned for additional information.  \n1. PRIORITY:  \n\n| [ ] | a. Standard |  |\n| --- | --- | --- |\n| [ ] | b. Date of Service | Services scheduled for this date: |\n| [ ] | c. Urgent | Provider certifies that applying the standard review time frame may seriously jeopardize the life or health of the member |\n\n2. PATIENT INFORMATION:  \n\n| a. Name (First): | b. Last: |  |  | c. MI: |  | d. DOB(mm/dd/yyyy): |\n| --- | --- | --- | --- | --- | --- | --- |\n| e. Gender: [ ] Male [ ] Female |  | f. Height: |  |  | g. Weight: |  |\n| h. Address: |  | i. City, State, Zip: |  |  | j. Phone: |  |\n| k. Health Plan ID \\#: |  |  | l. Group \\#: |  |  |  |\n\n3. ORDERING PHYSICIAN/CLINIC INFORMATION:  \n\n| a. Name: | b. TIN/NPI\\#: | c. Specialty: | d. Contact Name: |\n| --- | --- | --- | --- |\n| e. Clinic Name: |  | f. Clinic Address: |  |\n| g. City, State, Zip: |  | h. Phone: | i. Fax or email: |\n\n4. RENDERING PHYSICIAN/CLINIC/FACILITY/PHARMACY INFORMATION: [ ] Check if same as 3.  \n\n| a. Name: | b. TIN/NPI\\#: | c. Specialty: | d. Contact Name: |\n| --- | --- | --- | --- |\n| e. Physician/Clinic/Facility/Pharmacy Name: |  | f. Address: |  |\n| g. City, State, Zip: |  | h. Phone: | i. Fax or email: |\n\n5. REQUESTED MEDICAL PROCEDURE/COURSE OF TREATMENT/DEVICE INFORMATION:  \n\n| a. Service Type: |\n| --- |\n| b. Setting/CMS POS Code: Outpatient [ ] Inpatient [ ] Home [ ] Office [ ] *Other [ ] |\n| c. *Please specify if other: |\n\n6. HCPCS/CPT/CDT CODES  \n\n| a. Latest ICD Code | b. HCPCS/CPT/CDT Code | c. Code Description | d. Medical Reason |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\nOther Clinical Information – Include/attach clinical/office notes, laboratory information, imaging reports, and any guiding documentation to support medical necessity. If this is an out-of-network request, please provide an explanation.  \n69O-161.011  \nOIR-B2-2180 New 12/16  \nOptum Rx  \nPhone: 1-800-711-4555  \nFax: 1-844-403-1027  \n7. OTHER SERVICES (SEE INSTRUCTIONS)  \n\n| a. Type of Service: |  | b. Name of Therapy/Agency: |  |\n| --- | --- | --- | --- |\n| c. Units/Volume/Visits Requested: | d. Frequency/Length of Time Needed: |  | e. Initial [ ] Extension [ ] Previous Authorization \\#: |\n| f. Additional Comments: |  |  |  |\n\n8. PRESCRIPTION DRUG  \n\n| a. Diagnosis name and code: |  |  |  |\n| --- | --- | --- | --- |\n| b. Medication Requested | c. Strength | d. Dosing Schedule (including length of therapy) | e. Quantity Per Month or Quantity Limits |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n| f. Is the patient currently treated with requested medication(s): [ ] Yes [ ] No If yes, When was treatment with the requested medication started? |  |  |  |\n| g. Explain the medical reasons for the requested medications, including an explanation for selecting these medications over alternatives: |  |  |  |\n| h. List any other medications patient will use in combination with requested medication: |  |  |  |\n\n9. PREVIOUS SERVICES/THERAPY (INCLUDING DRUG, DOSE, DURATION, AND REASON FOR DISCONTINUING PREVIOUS THERAPY)  \n\n| a. | Date Discontinued |\n| --- | --- |\n| b. | Date Discontinued |\n| c. | Date Discontinued |\n\nAdditional Information – Please attach and submit any progress notes, lab data, discharge summaries, or other guiding documentation to support discontinuation of previous therapy and initiation of therapy with the requested medication along with a copy of the prescription.  \n10. ATTESTATION  \nI hereby certify and attest that all information provided as part of this prior authorization request is true and accurate.  \nProvider Signature:  Date:   \n69O-161.011  \nOIR-B2-2180 New 12/16  \nOptum Rx  \nPhone: 1-800-711-4555  \nFax: 1-844-403-1027  \nDO NOT WRITE BELOW THIS LINE: FIELDS TO BE COMPLETED BY PLAN  \nAuthorization \\#  Contact Name:","cbCaiupkxIU0gF0b","https://ap.wps.com/l/cbCaiupkxIU0gF0b","pdf",358399,"English","# PRIORITY\n# PATIENT INFORMATION\n# ORDERING PHYSICIAN/CLINIC INFORMATION\n# RENDERING PHYSICIAN/CLINIC/FACILITY/PHARMACY INFORMATION\n# REQUESTED MEDICAL PROCEDURE/COURSE OF TREATMENT/DEVICE INFORMATION\n# HCPCS/CPT/CDT CODES\n# OTHER SERVICES (SEE INSTRUCTIONS)\n# PRESCRIPTION DRUG\n# PREVIOUS SERVICES/THERAPY\n# ATTESTATION","[{\"question\":\"What information is required for the priority section of this form?\",\"answer\":\"The form requires selection of standard or date of service, and an urgent certification statement indicating that applying the standard review timeframe may jeopardize the member’s life or health.\"},{\"question\":\"Which details must be provided for patient information?\",\"answer\":\"It collects the patient’s first and last name, MI, date of birth, gender, height and weight, address and city/state/ZIP, phone, health plan ID number, and group number.\"},{\"question\":\"What must be included for prescription drug requests?\",\"answer\":\"The form requires diagnosis name and code, the medication requested, strength, dosing schedule including therapy length, quantity per month or quantity limits, whether the patient is currently on the requested medication (and start date if yes), and medical reasons for selecting it over alternatives.\"}]","Prior Authorization Form - Medical Information | PDF",1789624013]