Incomplete, illegible or inaccurate forms will be returned to sender 2026

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4.1 out of 5

58 votes

The document is a Prior Authorization form for the Elderly Waiver DTR Notification, which must be completed by a UCare Delegated Care Coordinator. It outlines the necessary member and provider information, services requested (including denial, termination, or reduction of services), and instructions for submission. The form emphasizes the importance of accuracy and completeness to avoid delays in processing.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the MEMBER INFORMATION section. Ensure that you provide your full name, member ID, address, city, state, zip code, date of birth, and phone number clearly.
In the CC INFO section, enter the Care Coordinator's name and phone number accurately.
Complete the ATTENDING HEALTH CARE PROFESSIONAL INFO section with the ICD-10 code and clinician details. Make sure all fields are legible.
Fill in the NEW OR CURRENT EW DATE SPAN with accurate dates. This is crucial for processing your request.
In the SERVICES/PROCEDURES/ITEMS REQUESTED section, select appropriate options for denial, termination, or reduction and provide a reason code if applicable.
Lastly, ensure that all provider information is filled out correctly including name, UCare ID/NPI number, phone number, and fax.

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Versions	Form popularity	Fillable & printable
2019	4.5 Satisfied (45 Votes)
2018	4.1 Satisfied (58 Votes)

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