Get Prior Authorization Request And Notification Form - Uha

Filling out the Prior Authorization Request And Notification Form - UHA online can be a straightforward process if you follow the right steps. This guide will provide you with clear instructions to ensure that all necessary information is included accurately.

Follow the steps to effectively complete the Prior Authorization Request And Notification Form - UHA online

1. Click ‘Get Form’ button to obtain the document and open it in your preferred online editor.
2. Begin with the member information section. Fill in the patient's name, gender, date of birth in the format MM/DD/YYYY, patient member number, and indicate whether there is other insurance by selecting yes or no. Provide the patient's phone number.
3. Next, complete the requesting physician or provider information. Include the provider's name, specialty, a contact person’s name, and their phone and fax numbers. Additionally, provide the provider's address and indicate if there is a personal physician involved.
4. Proceed to the servicing provider information by detailing the servicing provider’s name and address, contact person, facility name, and the appropriate phone and fax numbers. Specify if the procedure falls under inpatient, ambulatory (outpatient) surgery, or other categories.
5. Fill in the clinical information section. List the procedures requested with corresponding CPT codes and dates. Describe the diagnosis and provide the ICD codes for each listed condition.
6. Indicate whether the patient’s condition is related to an accident. If yes, check the applicable option (employment, automobile, home, or other) and specify where relevant.
7. Ensure the physician acknowledgment section is completed with a signature from the physician or their agent, along with the date of signature.
8. Finally, review the form for completeness and accuracy. Save your changes, download, and print the document as needed, or share it with relevant parties.

Start filling out your Prior Authorization Request And Notification Form - UHA online today for timely processing.