celebrex / meloxicam - UHCCommunityPlan.com

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First found May 22, 2018

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24 HOUR – URGENT
CELEBREX / MELOXICAM
PRIOR AUTHORIZATION REQUEST FORM
Complete ENTIRE form and Fax to: 866-940-7328
SECTION A - PATIENT INFORMATION
Today‘s Date:
Member ID #:
City:
Phone:
Primary Insurance:
First Name:
Address:
State:
DOB:
Policy #:
Last Name:
Zip:
Allergies:
Group #:
Is the requested medication NEW □ or a CONTINUATION of THERAPY □? If so, start date:_____________
Is this patient currently hospitalized? □Yes
SECTION B - PHYSICIAN INFORMATION
First Name:
Address:
Phone:
Fax:
Office Contact Name / Fax Attention to:
□No
Last Name:
City:
NPI #:
Medication:
M.D./D.O.
State:
Specialty:
Zip:
Strength:
Directions for use:
Diagnosis (Please be specific & provide as much information as possible):
Prescribed dose:
ICD-10 Code:
Frequency of administration
Does the patient have a diagnosis of Familial Adenomatous Polyposis (FAP) or ankylosing spondylitis in
the last 730 days? YES or NO (Circle Answer)
Does the patient have a history of Pepitc Ulcer Disease (PUD) or Gastrointestinal Bleed in the last 730
days? YES or NO (Circle Answer)
Does the patient have a history of warfarin therapy for 30 days in the last 45 days? YES or NO (Circle
Answer) If yes dates of therapy: ___________________________________________
Does the patient have a history of corticosteroid therapy for at least 35 days in the last 90 days? YES
or NO (Circle Answer) If yes list drug name and dates of therapy: ____________________
Has the patient taken high dose NSAID therapy for 30 days in the last 45 days? YES or NO (Circle
If yes list drug name and dates of therapy: ________________________________
Answer)
Does the patient have a diagnosis for at least one of the following? (Check correct answer)
□ Rheumatoid Arthritis □ Juvenile Rheumatoid Arthritis □ Osteoarthritis
□ None
Does the patient have a history of a DMARD agent for 30 days in the last 60 days?
YES or NO (Circle Answer) If yes list drug name and dates of therapy: ____________________
Does the patient have a history of 2 or more NSAID agents for 30 days in the last 180 days?
YES or NO (Circle Answer) If yes list drug name and dates of therapy: ____________________
Physician Signature: ________________________
_______________ Date: _______________
Confidentiality Notice: This transmission contains confidential information belonging to the sender and UnitedHealthcare. This information is intended only for
the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action involving the contents
of this document is prohibited. If you have received this telecopy in error, please notify the sender immediately.
Phone: 800-310-6826
Fax: 866-940-7328
Website: www.uhccommunityplan.com
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