Fillable Standard Prior Authorization Request Form Please submit your (United Health)

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Standard Prior Authorization Request Form Please submit your (United Health)

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The Standard Prior Authorization Request Form Please submit your (United Health) form is 1 page long and contains:

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  • 48 other fields

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PCA-1-19-01613-Clinical-Web_11192019
© 2019 United HealthCare Services, Inc.
Standard Prior Authorization Request Form
Please submit your request online using our Prior Authorization and Notification tool on Link. You can access the tool
at UHCprovider.com/paan. You may also initiate your request by phone by calling the number on the back of the
member’s health plan ID card.
Section I — Date and Time Submitted: _______________________________________________ a.m. / p.m. ET/MT/CT/PT
Section II — General Information
Review Type: Routine Urgent
Clinical Reason for Urgency
Request Type: Initial Request
Extension/Renewal/Amendment
(Prev. Auth. #: ________________________________________ )
Section III — Patient Information
Name
Patient Preferred Phone #
DOB
Sex: □ Male □ Female
Subscriber Name (if different)
Member ID #
Group #
Section IV ― Provider Information
Service Provider or Facility Name
NPI # or Tax ID #
Specialty
NPI # or Tax ID #
Specialty
Phone
Phone
Address
Name of Primary Care Provider
Phone
Section V ― Services Requested (with CPT, CDT or HCPCS Code) and Supporting Diagnoses (with ICD-10 Code)
Planned Service or Procedure
Code(s)
Start
Date
End
Date
Diagnosis Description
Code(s)
□ Inpatient □ Outpatient □ Provider Office □ Observation □ Home □ Day Surgery □ Other (specify)
□ Physical Therapy □ Occupational Therapy □ Speech Therapy □ Cardiac Rehab □ Mental Health/Substance Abuse
Number of sessions
Duration Frequency
Other
□
Home Health
MD signed order must be attached to this request. Please also attach the nursing assessment.
Number of visits requested
Duration Frequency
Other
□Durable Medical Equipment
MD signed order must be attached to this
request. Equipment/Supplies (Include Any HCPCS Codes)
Duration
Section VI ― Clinical Documentation: Please provide a brief explanation of medical necessity for service(s)
and attach supporting clinical documentation with this request.
Please provide contact information in case we need more information.
Name: ________ Phone ________ (ext. _________) email
__________________________________________ Preferred method of contact is: □ phone □ email
Section VII ― Reason for Denial or Partial Denial
A list of services that require prior authorization is available at UHCprovider.com/en/prior-auth-advance-notification.html.
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Standard Prior Authorization Request Form Please submit your (United Health)

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Completed 21 May 2021

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