Prior Authorization Form
All items marked in red are required.
 
This form cannot be used for Retrospective Reviews - If the End Date of your request is in the past, you must contact Optum directly using the phone number on the Member's ID card to complete a Retrospective Review.
By clicking the Submit Request button, you are attesting to the fact that all of the information provided is accurate and reflected in the patient's medical record.



Section 1: Submitter Information

  
  

Section 2: Service Provider or Facility Information

  
  
  
  


Section 3: Member Information

  

Section 4: Services Requested and Supporting Diagnoses

  
IMPORTANT NOTES: - If Outpatient Level of Care is selected, neither Attending nor Utilization Review contact information will be requested. The associated fields will be disabled.
  - If Attending Physician is unknown, please enter Admitting Physician's information in the Attending fields.
  - The Number of Days/Sessions field must be filled with numbers only.
  - Please use accepted DSM-V codes for the Diagnosis fields only.
  
  



    
6/19/2019 ]
6/19/2019 ]
    
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