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LAST MODIFIED 09.28.2018

Use this form when requesting prior authorization for medical drugs in Oregon.

PDF
LAST MODIFIED 04.18.2019

Clinical and Therapy Request Form for UnitedHealthcare Clinical Services Medical Management

PDF
LAST MODIFIED 01.09.2019

UnitedHealthcare Clinical Services and Therapy Request Form

HTML
LAST MODIFIED 05.03.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.

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LAST MODIFIED 05.04.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.

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LAST MODIFIED 09.10.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.

HTML
LAST MODIFIED 09.10.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.

HTML
LAST MODIFIED 05.03.2018

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.