Clinical and Therapy Request Form for UnitedHealthcare Clinical Services Medical Management

UnitedHealthcare Clinical Services and Therapy Request Form

UnitedHealthcare Community Plan Pharmacy prior authorization guidelines for AZ - Preferred Non-Solid Dosage Forms

UnitedHealthcare Community Plan Pharmacy prior authorization guidelines for CA - Preferred Non-Solid Dosage Forms

In order to be considered for network participation, you must fully complete this form.

OAR 836-053-1205: Exhibit 1, Uniform Prior Authorization Prescription Request, form (440-4992)

UnitedHealthcare Community Plan Pharmacy prior authorization guidelines for LA - Preferred Non-Solid Dosage Forms

Prior Authorization Fax Form

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 Mississippi Community Plan care providers.

Use this paper fax form to submit requests for the following state plans: Washington UnitedHealthcare Community Plan

Use this paper fax form to submit requests for the following state plans: Arizona AHCCCS/Medicaid, Arizona Children's Rehabilitative Services (CRS) Program, Arizona Developmentally Disabled Program, Arizona Long Term Care

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Michigan UnitedHealthcare Community Plan