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Prior Authorization Fax Request Form 800-771-7507

This FAX form has been developed to streamline the request process, and to give you a response as quickly as possible. Please complete all fields on the form, and refer to the listing of services that require authorization; you only need to request authorization for services on that list Date: _____________________________________________________ From: _____________________________________________ Contact Name _______________________ Telephone #: _______________________________________ Fax #: ______________________________ : Type of Service:

DME Hospice Services Prosthetic / Orthotics Inpatient Elective Surgery Transplantation Evaluation

Provider Information:

Cosmetic or Reconstructive

Surgery

PT / OT / ST MRI, MRA or PET Scan Gastric Bypass Evaluation &

Surgery

Home Health Care Services Skilled Nursing Facility Hysterectomy Other _____________________

Date of Service: _________________________________ Attending Physician or Surgeon: ____________________ Address: _______________________________________ Facility: ________________________________________

Provider ID:__________________________ Phone #: ____________________________ Fax #: ______________________________ PAR or Non-PAR (please circle one)

Member Information: Member Information: Member Name: _______________________ Member ID #: _______________ Date of Birth: ____________ Is request related to MVA or work-related injury? Does member have other insurance?

Yes No

Yes No

Medicare

Part A Part B

Other insurance name: ___________________________________________________________________ Clinical Information: Clinical Information: Diagnoses:_____________________________________________________________________________ ICD ­ 9 Codes: _________________________________________________________________________ Procedures: ____________________________________________________________________________ CPT Codes: ____________________________________________________________________________ Number of visits:_______________ Duration:____________________ Frequency: ____________________ Note: Please submit any pertinent clinical data (i.e. progress notes, treatment rendered, tests, labs, radiology reports) to support request for services.

UnitedHealthcare of New York, Inc.

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Prior Authorization

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