Prior Authorization Form

Our goal is to provide the most appropriate and timely care for our mutual patients. To this end, "Urgent" is defined as: Medical services that are needed in a timely or urgent manner that would subject the member to adverse health consequences without the care or treatment requested. University of Utah Health Plans reserves the right to classify urgent requests as standard requests when this definition is not met.

* Required Fields
Request Information
Request Type:    
Referral Request:  *    
Treatment Type:  *          
Main Contact Information

Please provide information about the main person who we can contact about this referral. This is usually the person who is filling out this form or the person who is making the connection to the patient. Failure to submit the correct information may result in processing delays, closed requests or denial.

Patient Information

Urgent requests will be completed in 72 hours and standard requests will be completed in 15 calendar days when all required documentation is received. To provide better patient care and to avoid delays, submit a fully completed form and complete clinical documentation. Failure to submit required documentation may result in processing delays, closed requests or denial.

Procedure:
CPT Code / HCPC:  *
ICD-10:  *
Units / Visits:
Estimated Costs:
Physician Information
Service Facility Information
Notes
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