Prior Authorization form

Step 1 of 4

Provider Information

SERVICING PROVIDER/VENDOR/LAB’S NAME & ADDRESS:(Required)

IF YOU DO NOT ENTER AN ADRESS YOUR REQUEST WILL BE AUTOMATICALLY REJECTED

TAX ID NUMBER(Required)

NPI(Required)

UnitedHealthcare(Required)

Yes

AETNA(Required)

Yes

REFERRING/PRESCRIBING PHYSICIAN’S NAME:(Required)

Please Identify Specialty(Required)

PCP

SERVICING FACILITY NAME & ADDRESS(Required)

IF YOU DO NOT ENTER AN ADRESS YOUR REQUEST WILL BE AUTOMATICALLY REJECTED

TAX ID NUMBER(Required)

NPI(Required)

UnitedHealthcare(Required)

Yes

AETNA(Required)

Yes

OFFICE CONTACT

Phone(Required)

FAX(Required)

Patient Information

PATIENTS NAME:(Required)

BIRTH DATE:

MEMBER ID:

PLACE OF SERVICE:

Physician’s Office

Patient’s Home

Radiology Center

Freestanding Facility

Ambulatory Surgery Center

Outpatient Hospital Care

Inpatient Hospital Care

Other

EXPLAIN:(Required)

ANTICIPATED DATE OF SERVICE:

Please enter all codes requested; “by report” codes must have a description of why the code is being used

ICD-10 CODE(S):(Required)

CPT CODE(S):(Required)

HCPCS CODE(S):(Required)

COST ESTIMATE:(Required)

IF YOU DO NOT ENTER AN ACCURATE ESTIMATE YOUR REQUEST WILL AUTOMATICALLY BE REJECTED.

Please Provide the following documentation:

History and physical and/or consultation notes including:

Clinical findings (e.g., pertinent symptoms an duration
Comorbidities
Activity and functional limitations
Family history if applicable
Reason for procedure/test/device, when applicable
Pertinent past procedural ad surgical history
Past and present diagnostic testing and results
Prior conservative treatments, duration and response
Treatment plan (e.g., surgical intervention)

Consultation and medical clearance report(s), when applicable

Radiology report(s) and interpretation (e.g., MRI, CT, discogram)

Laboratory results

Other pertinent multidisciplinary notes/reports: when applicable (e.g., psychological or psychiatric evaluation, physical therapy, multidisciplinary pain management)

File Upload(Required)

Drop files here or

Max. file size: 32 MB.

For Questions: Call Customer Services (866) 752-8881 to 855-773-7810

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Form Completed by (Name, Organization) :(Required)