PRIOR AUTHORIZATION FORM
Phone: (877) 370-2845 opt 2
Fax: (888) 992-2809
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Instructions:
Please complete the form located on page two. Fields with an asterisk ( * ) are required.
Please include all clinical information, x-ray reports, and diagnostic test results supportive of
the procedure(s) requested
You now have several options for submitting your Prior Authorization
requests to OptumCare:
If you have your own secure system, please submit authorization
requests to: LCD_UM@optum.com
If you do not have a secure email in place, please contact our service
center at 1-877-370-2845. We will ask for your email address and will
send a secure email for Prior Authorization requests to be sent to our
office.
You can fax your requests to 1-888-992-2809
Or mail the completed form to:
OptumCare
Attention: Prior Authorization
PO Box 46770
Las Vegas, NV 89114-6770
PRIOR AUTHORIZATION FORM
Phone: (877) 370-2845 opt 2
Fax: (888) 992-2809
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PLEASE MARK ONE OF THE FOLLOWING:
ROUTINE (Normal, non-urgent request)
DATE SENSITIVE (Date Sensitive is defined as an upcoming date of service)
URGENT (Urgent is defined as significant impact to health of the member if not completed within 72 hours)
PATIENT INFORMATION:
LAST NAME: FIRST NAME: DOB:
PHONE:
INSURED
ID:
ADDRESS: CITY:
STATE: ZIP:
REQUESTING PROVIDER INFORMATION:
PROVIDER NAME:
GROUP NAME:
SPECIALTY:
TAX ID #:
ADDRESS:
CITY: STATE: ZIP:
CONTACT NAME:
PHONE: EXT:
FAX:
PLACE OF SERVICE INFORMATION:
PROVIDER/FACILITY:
GROUP NAME:
SPECIALTY:
TAX ID #:
ADDRESS:
CITY: STATE: ZIP:
CONTACT NAME:
PHONE: EXT:
FAX:
SERVICES: DOS: DME ITEMS (CHECK ONE): RENTAL PURCHASE
TYPE OF SERVICE: OUTPT INPT Office Surgery Ctr SNF Home Other:
DIAGNOSIS CODE(S):
CPT/HCPCS CODE(S) (INCLUDE NUMBER OF UNITS PER CODE):
PLEASE ATTACH SUPPORTING CLINICAL INFORMATION (E.G., PLAN OF CARE, MEDICAL RECORDS, LAB
REPORTS, LETTER OF MEDICAL NECESSITY, PROGRESS NOTES, ETC.)
ALL SECTIONS OF THIS FORM MUST BE COMPLETED.
ON ADVERSE DETERMINATIONS, A RECONSIDERATION/EXPEDITED APPEAL MAY BE REQUESTED.
This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility, benefits available
at the time the service is rendered, contractual terms, limitations, exclusions, and coordination of benefits, and other
terms & conditions set forth in the member’s Evidence of Coverage.
The information contained in this form, including attachments, is privileged and confidential & is only for the use of
the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee
or the agent responsible to deliver to the intended recipient, the reader is hereby notified that any dissemination,
distribution, or copying of this communication is strictly prohibited. If this communication has been received in error,
the reader shall notify sender immediately and shall destroy all information received.