Prior Authorization Form


Our goal is to provide the most appropriate and timely care for our mutual patients. To this end, "Expedited" is defined as: Processing within the standard timeframe will jeopardize the life or health of the member and impact ability to regain maximum function. Health Choice Utah reserves the right to classify expedited requests as standard requests when this definition is not met. Expedited requests will be completed within 72 hours and standard requests will be completed within 14 calendar days when all required documentation is received.

Please Note: For SNF, Acute Rehab and LTAC requests you can also fax the following Authorization Request for Inpatient, ICF, SNF, Acute Rehab, and LTAC form to fax 801-213-2132.

* Indicates that the field is required.

Request Information

Please select the appropriate category: Service Request, Inpatient Request, Medication, or Behavioral Health

Is this related to a clinical trial?

Main Contact Information

Please provide information about the main person we can contact about this authorization. This is usually the person who is filling out this form or the person who is making the connection to the patient. Failure to submit the correct information may result in processing delays, closed requests or denial.

Patient Information

Expedited requests will be completed in 72 hours and standard requests will be completed in 14 calendar days when all required documentation is received. To provide better patient care and to avoid delays, submit a fully completed form and complete clinical documentation. Failure to submit required documentation may result in processing delays, closed requests or denial.

Procedures

Procedure 1

Requesting Provider Information

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Requesting Provider Contact Information

Servicing Provider Information

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- OR -

Servicing Provider Contact Information

Service Facility Information

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Service Facility Contact Information

Notes

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