University Health Plans - University of Utah Health Care - Salt Lake City, Utah

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.

* Required Fields

Request Information


   
~By selecting 'new', this will create a new authorization~








Main Contact Information

Please provide information about the main person we can contact about this authorization. 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

Expedited 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.

CPT Code/HCPC: *
ICD-10: *
Quantity: *
Type:
Visits:
Procedure Desc:
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Requesting Physician Information


Servicing Provider Information






- OR -

Service Facility Information

Notes

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