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The form collects clinical information such as the patient’s diagnosis, prior therapy history within 180 days, medication effectiveness confirmation, and any failures, contraindications, or intolerances with dates. The prescriber must attest that provided information is true and accurate, then fax to the listed toll-free numbers for coverage review.",{"@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-request-form-complete-and-fax/287456/",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-request-form-complete-and-fax/287456.png","ImageObject",442,249,{"name":88,"@type":89},"Dozel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What sections are required to submit this Prior Authorization Request Form?","Question",{"text":108,"@type":109},"It requires Member Information, Provider Information, Medication Information, and Clinical Information, plus a prescriber attestation section with signature and date.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should continuation of therapy be answered and what additional questions apply?",{"text":113,"@type":109},"Check whether therapy is continuing, and if “YES,” answer whether the member has used the medication in the last 180 days and whether the prescriber confirms the medication has been effective.",{"name":115,"@type":106,"acceptedAnswer":116},"Where and how should the completed form be sent for review?",{"text":117,"@type":109},"Fax the completed form to the toll-free number listed in the instructions; coverage will be determined based on the benefit plan’s rules, and urgent requests should be handled by the listed phone number.","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},287456,1790215943,{"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":79,"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},962085662650,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Please note: All information below is required to process this request  \nMon-Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific  \nFor real time submission 24/7 visit [www.OptumRx.com](www.OptumRx.com) and click Health Care Professionals OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626  \nPrior Authorization Request Form  \nDO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED  \n\n| Member Information (required) |  |  |  | Provider Information (required) |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  |  | Provider Name: |  |  |\n| Insurance ID\\#: |  |  |  | NPI\\#: | Specialty: |  |\n| Date of Birth: |  |  |  | Office Phone: |  |  |\n| Street Address: |  |  |  | Office Fax: |  |  |\n| City: | State: | Zip: |  | Office Street Address: |  |  |\n| Phone: |  |  |  | City: | State: | Zip: |\n| Medication Information (required) |  |  |  |  |  |  |\n| Medication Name: |  |  | Strength: |  | Dosage Form: |  |\n| 􀂉 Check if requesting brand |  |  | Is the physician supplying the medication? 􀂉 Yes 􀂉 No |  |  |  |\n| Directions for Use: |  |  | Continuation of therapy? 􀂉 Yes 􀂉 No\u003Cbr>If “YES”, answer the following:\u003Cbr>Has member been on this medication in the last 180 days?* 􀂉 Yes 􀂉 No Does the prescriber confirm that the medication has been effective in treating the member’s medical condition?* 􀂉 Yes 􀂉 No |  |  |  |\n| Clinical Information (required) |  |  |  |  |  |  |\n| Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient’s benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form, prescription benefit coverage will be determined based on the benefit plan’s rules. |  |  |  |  |  |  |\n| What is the patient’s diagnosis for the medication being requested? |  |  |  |  |  |  |\n| Please provide the medications the member has a failure, contraindication, or intolerance to:\u003Cbr>Medication:   Date:   Medication:   Date:   Medication:   Date:   Medication:   Date:   |  |  |  |  |  |  |\n| Prescriber attestation:\u003Cbr>Does the prescriber attest that the information provided is true and accurate to the best of their knowledge and understand that UnitedHealthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the information provided? 􀂉 Yes 􀂉 No\u003Cbr>Prescriber’s signature:   Date:   |  |  |  |  |  |  |\n\n* May not apply to all plans  \nAre there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?  \n________________________________________________________________________________________________________________  \n________________________________________________________________________________________________________________  \nPlease note: This request may be denied unless all required information is received within established timelines.  \nThis request may be denied unless all required information is received.  \nFor urgent or expedited requests please call 1-800-711-4555.  \nThis form may be used for non-urgent requests and faxed to 1-800-527-0531.","cbCaim40IvjoJNPe","https://ap.wps.com/l/cbCaim40IvjoJNPe","pdf",235345,"English","# Member Information (required)\n# Provider Information (required)\n# Medication Information (required)\n# Clinical Information (required)\n# Prescriber attestation","[{\"question\":\"What sections are required to submit this Prior Authorization Request Form?\",\"answer\":\"It requires Member Information, Provider Information, Medication Information, and Clinical Information, plus a prescriber attestation section with signature and date.\"},{\"question\":\"How should continuation of therapy be answered and what additional questions apply?\",\"answer\":\"Check whether therapy is continuing, and if “YES,” answer whether the member has used the medication in the last 180 days and whether the prescriber confirms the medication has been effective.\"},{\"question\":\"Where and how should the completed form be sent for review?\",\"answer\":\"Fax the completed form to the toll-free number listed in the instructions; coverage will be determined based on the benefit plan’s rules, and urgent requests should be handled by the listed phone number.\"}]","Prior Authorization Request Form - Complete and Fax | PDF",1789632350]