United Healthcare - Urgent - 24 Hour - Specialty Medication Prior Authorization Cover Sheet

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Prior Authorization Request Form

Fax Back To: (866) 940-7328

URGENT – 24 HOUR

Phone: (800) 310-6826

Specialty Medication Prior Authorization Cover Sheet

(This cover sheet should be submitted along with a Pharmacy Prior Authorization Medication Fax

Request Form. Please refer to

for medication fax request forms.)

Patient Information

Patient’s Name:

Insurance ID:

Date of Birth:

Height:

Weight:

Address:

Apartment #:

City:

State:

Zip:

Phone Number:

Alternate 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:

Physician Signature**:

DAW (Initial here):

Physician Signature**: By signing above the physician is providing the specialty pharmacy with a prescription that can be

used to facilitate the dispensing and/or coordination of delivery for the requested medication.

Medication Instructions

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

Yes

Is this medication a New Start?

Yes

If NO please provide the following:

Initiation Date:

Date of Last Dose:

**Please attach any pertinent clinical information that would pertain to support stated diagnosis.

Additional clinical information may be needed depending on your patients plan, including medication(s)

previously tried and failed

Delivery Instructions

Note: Delivery coordination requires a “Physician Signature” above and complete

“Provider Information” and “Patient Information”

Note: All necessary ancillary supplies are provided free of charge to the patient at the time of delivery

Ship to: Physician’s Office

Patient’s Address

Date medication is needed:

Medication Administered: Home Health

Self Administered

LTC

Physician’s Office

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This electronic fax transmission, including any attachments contains information for or from UnitedHealthcare that may be confidential and/or privileged. The information contained

in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that any disclosure, copying,

distribution or use of the contents of this information is strictly prohibited by law and will be vigorously prosecuted. If you have received this electronic fax transmission in error,

please notify the sender immediately and destroy all electronic hard copies of the communications including attachments

Specialty Med Fax Cover Letter_C&S_9.11