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If you have questions, please call 800-310-6826. This form may contain multiple pages. Please complete all pages to avoid a delay in our decision.  \nAllow 24 hours for review.  \nMember Information Prescriber Information  \nMember Name: Provider Name:  \n\n| Medication Information |  |\n| --- | --- |\n| Medication: | Strength: |\n| Directions for use: | Quantity: |\n| Medication Administered: □ Self-Administered □ Physician’s Office □ Other:\u003Cbr>|  |\n\nClinical Information  \nAdditional information that may be important for this review  \n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Member ID: |  |  |  | NPI \\#: |  | Specialty: |  |\n| Date Of Birth: |  |  |  | Office Phone: |  |  |  |\n| Street Address: |  |  |  | Office Fax: |  |  |  |\n| City: | State: |  | ZIP Code: | Office Street Address: |  |  |  |\n| Phone: |  | Allergies: |  | City: | State: |  | ZIP Code: |\n| Is the requested medication: □ New or □ Continuation of Therapy? If continuation, list start date:   Is this patient currently hospitalized? □ Yes □ No If recently discharged, list discharge date:   Is this member pregnant? □ Yes □ No If yes, what is this member’s due date?   |  |  |  |  |  |  |  |\n\n\n| What is the patient’s diagnosis for the medication being requested?  \u003Cbr>\u003Cbr>ICD-10 Code(s):   |\n| --- |\n|  Please refer to the patient’s PDL at [www.uhcprovider.com](www.uhcprovider.com) for a list of preferred alternatives \u003Cbr>What medication(s) does the patient have a history of failure to? (Please specify ALL medication(s)/strengths tried, directions, length of trial, and reason for discontinuation of each medication) |\n| What medication(s) does the patient have a contraindication or intolerance to? (Please specify ALL medication(s) with the associated contraindication to or specific issues resulting in intolerance to each medication) |\n| Are there any supporting laboratory or test results related to the patient’s diagnosis? (Please specify or provide documentation) |\n\nProvider Signature:  Date:    \nConfidentiality Notice: This transmission contains confidential information belonging to the sender and UnitedHealthcare. This information is intended only for the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action involving the contents of this document is prohibited. If you have received this telecopy in error, please notify the sender immediately.","cbCairC1cTzDEyTq","https://ap.wps.com/l/cbCairC1cTzDEyTq","pdf",128059,"English","# Prior Authorization Request Form\n## Instructions and Submission\n## Member and Prescriber Information\n## Medication Information\n## Clinical Information\n## Provider Signature and Confidentiality Notice","[{\"question\":\"How should the prior authorization request be submitted and when is it reviewed?\",\"answer\":\"Complete the entire form and submit all pages to the fax number provided. Allow 24 hours for review to support a timely decision.\"},{\"question\":\"What medication details are required in the form?\",\"answer\":\"The form requests the medication name, strength, directions for use, quantity, and where the medication was administered (self-administered, physician’s office, or other).\"},{\"question\":\"Which clinical and supporting documentation fields must be completed?\",\"answer\":\"Include diagnosis with ICD-10 codes, whether therapy is new or continuation (with start date), hospitalization status (and discharge date if applicable), pregnancy status (with due date if yes), prior medication failures and contraindications/intolerances, and any supporting laboratory or test results documentation.\"}]","Prior Authorization Request Form - Review and Submission Details | PDF",1789623456]