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.

Form NameUpmc Auth Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesupmc for you prior auth form pdf, upmc authorization form, upmc prior authorizations, upmc prior auth form

Form Preview Example


Prior Authorization Form

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


Otherwise please return completed form to:



PHONE 800-979-UPMC (8762)

FAX 412-454-7722


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:



Drug Requested:

Brand Generic



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


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



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

How to Edit Upmc Auth Form Online for Free

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Step 1: Get the button "Get Form Here" and click it.

Step 2: So you should be within the document edit page. You can include, adjust, highlight, check, cross, insert or delete areas or text.

The following sections are what you will have to fill out to get your finished PDF file.

example of gaps in upmc medication prior auth form

Write down the data in the Medication Trial, Date of Therapy, Start Date, End Date, Strength, Frequency, List adverse reactionsside, Please provide any additional, Potiga Vimpat PA form, All PA forms available at, and July field.

upmc medication prior auth form Medication Trial, Date of Therapy, Start Date, End Date, Strength, Frequency, List adverse reactionsside, Please provide any additional, Potiga Vimpat PA form, All PA forms available at, and July blanks to fill

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Step 4: Come up with around two or three copies of the file to keep clear of any specific upcoming troubles.

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