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Completed forms must be faxed with required medical record documentation to meet established timelines.",{"@graph":14,"@context":73},[15,34,56],{"@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-request-form/283988/",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-request-form/283988.png","ImageObject",442,249,{"name":42,"@type":43},"8796093062539","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-28","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",18,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is the purpose of this prior authorization request form?","Question",{"text":63,"@type":64},"It gathers required member, provider, medication, and clinical information so coverage can be reviewed by the prescribing physician under the patient’s benefit plan rules.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How should an urgent prior authorization request be handled?",{"text":68,"@type":64},"Mark the urgency section as yes, and use the urgent or expedited contact option provided for urgent requests.",{"name":70,"@type":61,"acceptedAnswer":71},"What information is required under clinical justification for continuation of therapy?",{"text":72,"@type":64},"Answer whether the request is for continuation, whether the patient can be safely transitioned to another covered medication, and whether relevant chart documentation will be submitted.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283988,1790190043,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},"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":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":11,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":129,"file_id":130,"file_url":131,"file_type":132,"file_size":133,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":134,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":135,"faqs":136,"seo_title":137,"seo_description":12,"update_tm":138,"read_time":4},8796093062539,"Optum Rx has partnered with CoverMyMeds to receive prior authorization requests , saving you time and often delivering real-time determinations. [Visit](Visit go.covermymeds.com/OptumRx to)[ ](Visit go.covermymeds.com/OptumRx to)[go.covermymeds.com/OptumRx](Visit go.covermymeds.com/OptumRx to)[ to](Visit go.covermymeds.com/OptumRx to) begin using this free service. Please note: All information below is required to process this request.  \nMon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific  \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 |  |  | Directions for Use: |  |  |  |\n| Clinical Information (required) |  |  |  |  |  |  |\n| Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses Optum Rx 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| Urgency:\u003Cbr>Is this request urgent? 􀂉 Yes 􀂉 No |  |  |  |  |  |  |\n| Continuation of therapy*,¥ :\u003Cbr>Is this request for continuation of therapy? 􀂉 Yes 􀂉 No\u003Cbr>If yes , can the patient be safely and effectively transitioned to another covered medication? 􀂉 Yes 􀂉 No Will medical records be submitted documenting any of the information below? 􀂉 Yes 􀂉 No\u003Cbr>Has the member been on the requested medication in the last 180 days or is currently stabilized? 􀂉 Yes 􀂉 No Has the requested medication been safe and effective in treating the member's medical condition? 􀂉 Yes 􀂉 No\u003Cbr>Has the member tried another prescription drug in the same pharmacological class or same mechanism of action? 􀂉 Yes 􀂉 No Were prior medications discontinued due to a lack of efficacy or effectiveness, diminished effect, or an adverse event? 􀂉 Yes 􀂉 No |  |  |  |  |  |  |\n| What is the member’s diagnosis for the medication being requested?*\u003Cbr>Diagnosis:   ICD-10 Code(s):   |  |  |  |  |  |  |\n| Please provide the medications the member has a failure, contraindication, or intolerance to* :\u003Cbr>Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   |  |  |  |  |  |  |\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  \n¥ Please note: Chart documentation of the above is required to be submitted along with this fax form  \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________________","cbCaivEeBoJbqZvF","https://ap.wps.com/l/cbCaivEeBoJbqZvF","pdf",148037,"English","# Member Information (required)\n# Provider Information (required)\n# Medication Information (required)\n# Clinical Information (required)\n## Urgency\n## Continuation of therapy\n## Diagnosis (ICD-10)\n## Prior medication failures, contraindications, or intolerance\n# Prescriber attestation\n# Fax submission and contact details","[{\"question\":\"What is the purpose of this prior authorization request form?\",\"answer\":\"It gathers required member, provider, medication, and clinical information so coverage can be reviewed by the prescribing physician under the patient’s benefit plan rules.\"},{\"question\":\"How should an urgent prior authorization request be handled?\",\"answer\":\"Mark the urgency section as yes, and use the urgent or expedited contact option provided for urgent requests.\"},{\"question\":\"What information is required under clinical justification for continuation of therapy?\",\"answer\":\"Answer whether the request is for continuation, whether the patient can be safely transitioned to another covered medication, and whether relevant chart documentation will be submitted.\"}]","Prior Authorization Request Form | PDF",1789624011]