Form - 440-4992; Uniform Prescription Drug Prior Authorization Request Form; Exhibit 1- OAR 836-053-1205;

Clinical and Therapy Request Form for UnitedHealthcare Clinical Services Medical Management

UnitedHealthcare Clinical Services and Therapy Request Form

Prior Authorization Fax Form

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Arizona Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Florida Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Hawaii Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Maryland Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Michigan Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Nebraska Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of New Jersey Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of New York Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Ohio Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Pennsylvania Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Rhode Island Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Texas Community Plan care providers.