Get Utah Department Of Health

Navigating the Utah Department Of Health's prior authorization request form for stimulants can be straightforward with the right guidance. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your prior authorization request form.

1. Click ‘Get Form’ button to access the prior authorization request form and open it for editing.
2. Begin by entering the patient's information in the designated fields. Provide the patient's name and Medicaid ID number clearly and accurately.
3. Next, fill in the prescriber’s details. Include the prescriber’s name, NPI number, and contact information, including the phone number, extension or option, and fax number.
4. Identify the pharmacy by entering its name along with the pharmacy phone number and fax number.
5. Indicate the requested medication along with its strength and the frequency of dosage per day.
6. Make sure all information is legible, complete, and correct. Incomplete forms will be returned.
7. Fax the necessary documentation from progress notes to 855-828-4992. This documentation should include letters of medical necessity and testing results when applicable.
8. Review any notes regarding specific diagnoses covered under this authorization and ensure your case fits within those parameters.
9. After completing the form and ensuring all information is accurate, you can save the changes, download, print, or share the form as necessary.

Complete your documents online today to streamline the authorization process.