Precertification Request Form

Thank you for your interest in submitting a pre-certification request via web-form. At this time, the web-form is only available on tablets, laptops, and desktops.

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Patient or Patient Healthcare representative: Utilization Review Plan Requirements - The following states have specific pre-cert requirements, please click on your state if listed below, if not, proceed below. If your state requires one of these special forms, please submit it via email to records@urmedwatch.com or by fax to (407) 333-8928.
ARIZONA STANDARD PRIOR AUTHORIZATION REQUEST FORM FOR HEALTH CARE SERVICES
AZ-Medication-DME-MedicalDevice
Texas IRO General Information
TEXAS REQUEST FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION (IRO) INSTRUCTIONS & FORM

You have accessed the MedWatch precertification form. Please enter as much information as possible in the spaces provided, even if you do not have all the information requested on this form. The data from this website is received daily during our regular business hours. You will receive a response within 24 hours of the first business day following the referral.

If you do not receive a response please contact MedWatch to verify that your information has been transmitted to us. We can be reached at 1-800-432-8421 from 7am-9pm ET Monday through Friday.
   
Insurance Information
Insurance Company Name
Group Name / ID
Precert Type
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IMPORTANT: ICDs/CPTs must be added one at a time. Please click Add to add an entry.
Once completed, click Save.
Diagnoses
Diagnosis 
Add
No Diagnoses have been added
Procedures
Procedure 
Procedure Date 
Add
No Procedures have been added
Admit Date (MM/DD/YYYY)
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Discharge Date (MM/DD/YYYY)
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Member PPO Network
Is this Primary Insurance
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If no, who is Primary Insurance Carrier
Patient Information
Member ID
Last Name
First Name
Date of Birth (MM/DD/YYYY)
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Gender
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Address
City
State
Zip
Phone
E-Mail
Insured Information
Member ID
Last Name
First Name
Date of Birth (MM/DD/YYYY)
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Gender
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Address
City
State
Zip
Phone
E-Mail
Physician Information
EIN / Tax ID
NPI
Last Name
First Name
Specialty
Type
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Is Physician In Network
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Address
City
State
Zip
Phone
Fax
Facility Information
EIN / Tax ID
NPI
Bill Type
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Name
Is Facility In Network
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Address
City
State
Zip
Phone
UR Contact Name
UR Phone
UR Fax
Submitter Information
Name
Phone
Relationship to Patient
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Notes (Reason for Precertification)
Submission of this data to Medwatch does not verify certification, benefits, or coverage. Please contact Medwatch at 1-800-432-8421 for certification questions. Please contact your claims office for benefits or payment information.
  • Address
  • MedWatch LLC
  • P.O. Box 952679
  • Lake Mary, FL 32795-2679
  • Contact Us
  • For quick and easy contact, use the Contact Form!
  • (800) 432-8421
  • Fax (407) 333-8928

For compliance or privacy concerns, please contact the MedWatch Compliance Department at 321-420-4150 or email ComplianceDept@urmedwatch.com