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It includes patient identifiers, health insurance ID, date of birth, gender identity, address and contact fields. It captures referring/requesting and rendering/attending provider data, then records required clinical information such as request date, out-of-network status, type of service, dates, facility, primary and secondary diagnoses, procedure name and billing codes. It also gathers any requested durable medical equipment details and whether supporting clinical information pages are attached.",{"@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/uniform-medical-prior-authorization-form/287391/",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/uniform-medical-prior-authorization-form/287391.png","ImageObject",442,249,{"name":88,"@type":89},"Kyle","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should complete the Uniform Medical Prior Authorization Form?","Question",{"text":108,"@type":109},"The form is completed using patient/member information plus referring/requesting provider details and rendering/attending provider details, including an office contact/person completing the form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What clinical details are required for the authorization request?",{"text":113,"@type":109},"Required fields include request date, whether the request is for out-of-network services, type of service selected, proposed dates of service, facility, diagnosis and diagnosis codes, and the proposed procedure with CPT/HCPCS or revenue code.",{"name":115,"@type":106,"acceptedAnswer":116},"How does the form handle requested durable medical equipment (DME)?",{"text":117,"@type":109},"It includes a dedicated section for DME with required code, duration, purchase price, and monthly rental price, and can specify additional equipment requested.","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},287391,1789632282,{"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":47,"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":125,"read_time":4},3985741905716,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Pre-Service Post-Service  \nElective  \nNon-Elective  \nUrgent  \nNon-Urgent  \nUniform Medical Prior Authorization Form  \nImportant: Please read your insurer’s (for individuals with commercial insurance) or Vermont Medicaid’s (for Medicaid  \nbeneficiaries) specific instructions for completing this form.  \nPatient/Member Information (* Required Field)  \n*First Name Middle Initial *Last Name  \n*Health Insurance ID\\# *DOB Gender Identity  \n*Address Apt.\\#  \n\n| *City | *State | *Zip | *Tel. |\n| --- | --- | --- | --- |\n\nReferring/Requesting Provider Information (* Required)  \nRendering/Attending Provider Information (* Required)   \n\n| *First Name | *Last Name |  | *First Name | *Last Name |  |\n| --- | --- | --- | --- | --- | --- |\n| *NPI/TIN\\# | *Specialty |  | *NPI/TIN\\# | *Specialty |  |\n| *Address |  | Suite | *Address |  | Suite |\n| *City |  | *State | *City |  | *State |\n| *Tel. | Fax\\# |  | *Tel. | Fax\\# |  |\n\n*Office Contact/Person Completing Form  \n\n| *Telephone No. | Fax No. |\n| --- | --- |\n\nRequired Clinical Information (* Required Field)  \n*Date of Request *Is this request for Out-of-Network Services? Y ☐ N ☐  \n*Type of Service Requested (check all that apply)  \n\n| Services: Obstetrics ☐ |  |  |  |  |  |  |  | Therapies: |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Medical Admit ☐ Immunotherapy Treatment ☐ |  |  |  |  |  |  |  | Occupational Therapy ☐ |  |  |\n| Mental Health/SUD ☐ Surgery (including Oral Surgery) ☐ |  |  |  |  |  |  |  | Physical Therapy ☐ |  |  |\n| Oncology ☐ Transplant ☐ |  |  |  |  |  |  |  | Speech Therapy ☐ |  |  |\n| Acupuncture ☐ Chiropractic ☐ |  |  |  |  |  |  |  | Applied Behavior Analysis ☐ |  |  |\n| Testing/Imaging:\u003Cbr>Diagnostic Imaging \u003Cbr>Diagnostic Medical Test  |  | Other:\u003Cbr>DME  SNF  Home Health  Vision/Glasses  Home Infusion  Other (please specify)  |  |  |  |  |  |  |  |  |\n| *Date Diagnosed: |  | *Place of Service: Telehealth/Audio Only |  |  |  |  |  |  |  | |\n|  |  | Inpatient  | Outpatient |  | | Office | | Other (please specify) | |  |\n| *Proposed Dates of Service: | From\u003Cbr>To |  |  | *Facility Where Service Will be Performed: |  |  |  |  |  |  |\n| *Proposed Number of Inpatient Treatment Days |  |  |  | *Proposed Number of Outpatient Treatment Visits |  |  |  |  |  |  |\n| *Primary Diagnosis |  |  |  | *Primary Diagnosis Code |  |  |  |  |  |  |\n| *Secondary Diagnosis |  |  |  | *Secondary Diagnosis Code |  |  |  |  |  |  |\n| *Name of Proposed Procedure |  |  |  | *CPT/HCPCS or Revenue Code |  |  |  |  |  |  |\n\n*Requested Durable Medical Equipment (DME)  \n\n| *DME CPT/HCPCS Code | *DME Duration |  |\n| --- | --- | --- |\n| *DME Purchase Price $ | *DME Monthly Rental Price | $ |\n\nAdditional Clinical Information Attached:  No. of pages:","cbCaimwZw6UJWkxH","https://ap.wps.com/l/cbCaimwZw6UJWkxH","pdf",254910,"English","# Patient/Member Information\n# Referring/Requesting Provider Information\n# Rendering/Attending Provider Information\n# Required Clinical Information\n# Durable Medical Equipment (DME)\n# Additional Clinical Information","[{\"question\":\"Who should complete the Uniform Medical Prior Authorization Form?\",\"answer\":\"The form is completed using patient/member information plus referring/requesting provider details and rendering/attending provider details, including an office contact/person completing the form.\"},{\"question\":\"What clinical details are required for the authorization request?\",\"answer\":\"Required fields include request date, whether the request is for out-of-network services, type of service selected, proposed dates of service, facility, diagnosis and diagnosis codes, and the proposed procedure with CPT/HCPCS or revenue code.\"},{\"question\":\"How does the form handle requested durable medical equipment (DME)?\",\"answer\":\"It includes a dedicated section for DME with required code, duration, purchase price, and monthly rental price, and can specify additional equipment requested.\"}]","Uniform Medical Prior Authorization Form | PDF"]