Get Medication Prior Authorization Request Form - Unitedhealthcare ...

Filling out the Medication Prior Authorization Request Form is an essential step in ensuring that your medication needs are met efficiently. This guide provides clear, step-by-step instructions to assist you in completing the form correctly online.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Medication Prior Authorization Request Form and open it in your document editor.
2. Begin by filling out the member name field with the full name of the individual requesting the medication.
3. In the provider name section, enter the name of the healthcare provider who is requesting the authorization.
4. Provide the member ID, ensuring it corresponds to the individual's health insurance information.
5. Complete the address section with the member's current residential address, including city, state, and zip code.
6. Record the phone number for the member to aid in communication regarding the request.
7. Fill in the fax number where necessary, which can be used for further correspondence or requests.
8. Indicate the member's date of birth in the required format to confirm their identity.
9. Specify the medical specialty relevant to the medication request, this will help in processing the request appropriately.
10. List the medication name along with its strength, ensuring that this aligns with the physician’s prescription.
11. Provide clear directions for use as prescribed by the healthcare provider.
12. Enter the diagnosis that justifies the need for the medication, ensuring it adheres to medical guidelines.
13. Document the date the patient started the medication, this is crucial for the evaluation of the prior authorization.
14. List any specific medications that the patient has tried and failed, as this information is critical for the review of the request.
15. Offer a clear reason for the non-formulary request. Note that patient chart notes may be required for further documentation.
16. The requesting physician must sign the form to validate the request and include the date of signing.
17. Add any additional notes that may assist in processing the prior authorization request.
18. Review all sections to ensure accuracy, and then save the changes, download, print, or share the completed form as needed.

Complete your Medication Prior Authorization Request Form online to ensure timely processing of your prescription needs.