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Get United Healthcare Prior Authorization Fax Request Form 2011-2024

Date: _____________________ Contact Person_____________________________________ Telephone #: ___________________ Fax #: _____________________Is this a HIPAA secure fax line? □ Yes □ No Requesting Provider: ________________________________ Telephone #: _________________________ Requesting Provider TIN/NPI: __________________________ Type of Request: □ Routine □ Urgent Urgent is defined as “significant impact to health of the member” □ Expedited (Medicare Only) Request from physi.

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