United Healthcare - Urgent - 24 Hour - Specialty Medication Prior Authorization Cover Sheet Page 2
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3URGENT – 24 HOUR
Hepatitis C Medication
PRIORAUTHORIZATION REQUEST FORM
Please complete both pages of form and Fax to: 866-940-7328
(NOTE: This form contains 2 pages. Failure to complete in entirety will delay decision.)
Today‘s Date:
SECTION A - PATIENT INFORMATION
First Name:
Last Name:
Member ID:
Address:
City:
State:
Zip:
Phone:
DOB:
Allergies:
Primary Insurance:
Policy #:
Group #:
□
□
NEW
CONTINUATION of THERAPY
Is the requested medication
or a
? If so, start date:_______________________
□
□
Yes
No
Is this patient currently hospitalized?
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
□
Ribavirin Product Requested (Include Strength):
Ribavirin Directions for Use:
□
Interferon Product Requested (Include Strength):
Interferon Directions for Use:
□
Sovaldi
Sovaldi Directions for Use:
□
Olysio
Olysio Directions for Use:
□
□
□
Victrelis
Incivek
Other Agent
Directions for Use:
Diagnosis:
ICD 9 Code:
This section MUST be completed for ALL patients with Hepatitis C
**ALL supporting labs and chart documentation is required for medical review of this request**
□ Genotype 1
□ Genotype 2
Genotype (MUST submit supporting lab documentation):
□ Genotype 3
□ Genotype 4
□ Other Genotype (Must specify)
__________________________
□ Hepatologist
□ Gastroenterologist
□ Infectious Disease Specialist
Prescriber Specialty:
□ Other (Must specify):_______________________________________________________________
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:
UHC-HepC- Updated 3.27.14
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