Fillable Prior Authorization Request Form printable pdf download

Prior Authorization Request Form

Fax Back To: 1-800-853-3844

Phone: 1-800-711-4555

5 AM – 7 PM PST M-F

Prior Authorization Form

Patient Information

Patient’s Name:

___________________________________________________________________________________________

Insurance ID:

Date of Birth:

Height:

Weight:

___________________________

_______________

Address:

Apartment #:

________________________________________________________________

______________________

City:

State:

Zip:

___________________________

Phone:

Alternative Phone

Sex:

Male

Female

___________________________

Provider Information

Provider’s Name:

Provider ID Number:

___________________________

____________________________________________

Address:

City:

State:

Zip:

___________________________

_____________

_______________

Suite Number:

Building Number:

___________________________

_________________________________________________

Phone Number:

Fax number:

___________________________

_________________________________________________

Provider’s Specialty:

_________________________________________________

Medication Information

Medication:

Quantity:

ICD9 Code:

___________________________

__________________________

_____________________

Directions:

Diagnosis:

Refills:

_____________________________

___________________________

_____________________

Will the physician supply this medication?

Yes

By providing the information it will only be used for coverage determination request administered by

OptumRx.

Medication Instructions

Has the patient been instructed on how to Self-Administer?

Yes

Is the medication a New Start?

Yes

If NO please provide the following:

Initiation Date:

Date of Last Dose:

_____________

This is to notify you that your patient’s request for this medication may be denied unless we receive

supportive information, i.e., medications tried and failed, document improvement with medication(s).

Please provide information to support this request. Please fax back at the number listed above or call at

1-800-711-4555.

Administration Instructions

Dispensing Location: Physician’s Office

Patient’s Address

Date Medication is needed:

_____________

Medication Administered: Home Health

Self Administered

LTC

Physician’s Office

*If you have any questions regarding your patient’s plan drug limits you may call us at: 1-800-711-4555.

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