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Get PEHP Health & Benefits Prior Authorization For Anesthesia Services For Dental Procedures Under 2018

PRIOR AUTHORIZATION for GENERAL ANESTHESIA for DENTAL SERVICES UNDER MEDICAL For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. If you have prior authorization or benefit questions, please call PEHP Customer Service at (801) 366-7555 or toll free at (800) 753-7490. Section I: PATIENT INFORMATION Name (Last, First MI): DOB:.

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