You'll find all forms we currently use in the following list.
We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check back frequently to see what's changed.
UnitedHealthcare hawk-i Forms
Member Appeal Form (English) (PDF 28.57 KB)
Member Appeal Form (Espanol) (PDF 32.23 KB)
Abortion Necessity Certification (PDF 17.76 KB)
Provider Dispute (PDF 74.03 KB)
Medical Record Review Form (PDF 13.99 KB)
Prescription Drug Prior Authorization Request Form (PDF 79.95 KB)
Prior Authorization Fax Request Form (PDF 116.65 KB)
Factor Prescription Request Form (PDF 104.97 KB)
Botulinum Toxins Prior Authorization Form (PDF 609.35 KB)
HP Acthar Gel Prior Authorization Form (PDF 558.22 KB)
Immune Globulin Prior Authorization Form (PDF 557.48 KB)
Makena Prior Authorization Form (PDF 529.8 KB)
Utilization Management Determination Form (PDF 98.19 KB)
Utilization Management Adverse Determination Form (PDF 98.6 KB)
Utilization Guidelines, such as Milliman Utilization Care Guidelines, may be used as part of the prior authorization process. You may request a copy of a specific guideline by calling 1-888-650-3462.