By submitting this form, you will begin the preauthorization or prenotification process. If preauthorizing, a member of the Medical Management Services staff will contact you within one business day of receipt to complete the submission. If you are required to prenotify us, your submission will be documented and a member of the Medical Management staff will contact you as needed.
Please complete all information requested. At the end of the form, you will be asked to "Submit" to send your request to UMR.
Have you verified this patient's eligibility and benefits?