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Get Great Lakes Medical Prior Authorization Form

UnitedHealthcare Great Lakes Prior Authorization List. This list can be found at www.UHCGreatLakes.com Physician providing Services (full name) Physician Address City Zip Facility Name (if applicable) IF Physician or Facility are Out-of-Network, state reason for referring Out-of-Network. CPT Codes *Procedure/Service ICD9 Codes Diagnosis Outpt Service Setting Date(s) of Service Not to exceed 180 days) Any other insurance? 23Hr/Obs Start: No Yes Inpt ASC Office - Number of Visits: En.

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