Prior Authorization Form
Our goal is to provide the most appropriate and timely care for our mutual
patients. To this end, "Expedited" is defined as: Medical services that are
needed in a timely or expedited 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 expedited requests as standard
requests when this definition is not met.
For SNF, Acute Rehab and LTAC requests, you can also fax the following For SNF, Acute Rehab and LTAC requests you can also fax the following form to fax 801-213-2132.
This form is not used for HOME Project Medicaid - please call 801-581-5515 or fax request to 801-585-5600.