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.
For SNF, Acute Rehab and LTAC requests, please download and use the SNF / LTAC / Acute Rehabilitation Authorization form
Do not use for CURRENT INPATIENT ADMISSIONS please submit clinical and face sheet to fax 801-758-3370