Fillable Unitedhealthcare Prior Authorization Request Form - Elidel/protopic printable pdf download

Unitedhealthcare Prior Authorization Request Form - Elidel/protopic

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24 HOUR – URGENT

ELIDEL/PROTOPIC

PRIOR AUTHORIZATION REQUEST

Complete ENTIRE form and Fax to: 866-940-7328

Today‘s Date:

SECTION A - PATIENT INFORMATION

First Name:

Last Name:

Member ID:

Address:

City:

State:

Zip:

Phone:

DOB:

Allergies:

Primary Insurance:

Policy #:

Group #:

□

Is the requested medication NEW

or a CONTINUATION of THERAPY

? If so, start date:_____________

□

Is this patient currently hospitalized?

Yes

SECTION B - PHYSICIAN INFORMATION

First Name:

Last Name:

M.D./D.O.

Address:

City:

State:

Zip:

Phone:

Fax:

NPI #:

Specialty:

Office Contact Name / Fax Attention to:

SECTION C - MEDICAL INFORMATION

Medication:

Strength:

Dosing frequency:

Directions for use:

Diagnosis (Please be specific & provide as much information as possible):

ICD-10 CODE:

Is the requested medication intended to be applied topically to the face, axillae (armpit), or genital area for this

patient? Yes____ No____

Has the patient been previously treated with at least two topical corticosteroids which resulted in an inadequate

response? Yes____ No____

List medications tried and dates of therapy: ______________________________________________________________

____________________________________________________________________________________________________

Did the patient experience an intolerance/ adverse reactions, or has a documented contraindication, to treatment

with at least two topical corticosteroids? Yes____ No____

List medications tried and adverse reaction/intolerance: ___________________________________________________

____________________________________________________________________________________________________

Physician Signature

Date:

: ________________________

_______________

Confidentiality Notice: This transmission contains confidential information belonging to the sender and UnitedHealthcare. This information is intended only for

the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action involving the contents

of this document is prohibited. If you have received this telecopy in error, please notify the sender immediately.

Phone: 800-310-6826

Fax: 866-940-7328

Website: