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.
| Question | Answer |
|---|---|
| Form Name | Upmc Auth Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | upmc prior auth forms for medications, upmc authorization form, upmc prior auth form, upmc prior authorizations |
POTIGA, VIMPAT
Prior Authorization Form
IF THIS IS AN URGENT REQUEST, Please Call UPMC Health Plan Pharmacy Services. |
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Otherwise please return completed form to: |
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UPMC HEALTH PLAN PHARMACY SERVICES |
PHONE |
FAX |
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
Please list other
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 |