Upmc Auth Form PDF Details

UPMC Auth Form is a web-based form that allows you to request access to UPMC's electronic resources from off-campus. This form can be used by authorized users who are not affiliated with UPMC, including current employees of other organizations and health care professionals who provide services to UPMC patients. After you have completed the form, your request will be reviewed by UPMC's security team. If approved, you will receive an email with instructions on how to access the resources.

You'll find more info about the upmc auth form by looking through the listing we compiled.

QuestionAnswer
Form NameUpmc Auth Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesupmc prior auth forms for medications, upmc authorization form, upmc prior auth form, upmc prior authorizations

Form Preview Example

POTIGA, VIMPAT

Prior Authorization Form

IF THIS IS AN URGENT REQUEST, Please Call UPMC Health Plan Pharmacy Services.

 

Otherwise please return completed form to:

 

UPMC HEALTH PLAN PHARMACY SERVICES

PHONE 800-979-UPMC (8762)

FAX 412-454-7722

PLEASE TYPE OR PRINT NEATLY

Please complete all sections of this form AND include details of past relevant medical treatment, which substantiates the need for an exception to using formulary alternatives, i.e. past prescription treatment failures, documented side effects, chart documentation, lab values, etc. Incomplete responses may delay this request.

Office Contact:

Provider Specialty:

Provider First Name:

Provider Last Name:

Provider Phone:

Provider Fax:

Provider NPI #:

Patient Name:

Patient UPMC Health Plan ID Number:

Patient DOB:

Patient

Age:

Drug Requested:

Brand Generic

Strength:

Frequency:

Qty Dispensed:

Generic equivalent drugs will be substituted for Brand name drugs unless you specifically indicate otherwise.

New medication

Ongoing medication

If ongoing, provide date started:

If medication is ongoing, Did member Show improvement while on therapy?

Yes No

Diagnosis:

Date of diagnosis:

Medical History

Does the member have a diagnosis of partial-onset seizures? Yes No

Please list other anti-epileptic drugs the member is currently taking in the space below.

Medication Trial

Date of Therapy

Start Date

End Date

Strength

Frequency

List adverse reactions/side

effects/reason for discontinuing

Please provide any additional information which should be considered in the space below:

Potiga, Vimpat PA form

All PA forms available at www.upmchealthplan.com/providers/pa_forms.html

July 2012

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