Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the Prior Authorization Form and open it in your preferred editing tool.
2. Begin by filling out the office contact information section. Include the provider specialty, first name, last name, phone number, and fax number.
3. Enter the patient's information, including their full name, UPMC Health Plan ID number, date of birth, age, and the requested drug along with its strength.
4. Specify the frequency of the medication and the quantity to be dispensed. Indicate if you are requesting a brand or generic medication. If the drug is ongoing, indicate the start date and whether the member showed improvement while on therapy.
5. Provide the diagnosis information, ensuring to mark whether it is a new or ongoing medication. If ongoing, include the date the medication started and the date of diagnosis.
6. Answer the medical history questions regarding fibromyalgia as applicable. If yes, provide copies of chart documentation showing the diagnosis, past therapies attempted, and evidence of trial for exercise or physical therapy.
7. Utilize the additional information space to provide any other relevant details that should be considered in support of the authorization request.
8. Once you complete all sections, review the form for accuracy, then save your changes. When finished, you can download, print, or share the form as needed.

Take action now by completing your Prior Authorization Form online for UPMC Health.