Medical, Behavioral and SUD Prior Authorization Form
Prior authorization request form for providers submitting medical, behavioral health, and substance use disorder service requests for Umpqua Health Alliance members.
Medication Management Referral Form
Referral form for submitting patients to Umpqua Health Alliance’s Medication Management Program, completed by the referring provider and submitted to UHA Pharmacy Services by fax or email.
Pharmacy Prior Authorization Criteria
Pharmacy Prior Authorization Criteria outlining Umpqua Health Alliance requirements and clinical criteria used to review prior authorization requests for covered pharmacy medications and related services.
Medication Prior Authorization Form
Prior authorization request form for prescription drugs submitted to Umpqua Health Alliance’s pharmacy team, requiring clinical documentation and provider information for formulary exceptions or non-covered medication requests.
Professionally Administered Drug (PAD) Prior Authorization Form
Prior authorization request form for professionally administered drugs (PAD), requiring supporting clinical documentation submitted to Umpqua Health Alliance’s pharmacy team by fax or phone.
Pharmacy Prior Authorization Grid
Umpqua Health Alliance’s pharmacy prior authorization grid listing prescription drug categories that require prior authorization, with fax and phone contact information and documentation requirements.
Grant Application Budget Form
Budget form for Umpqua Health Alliance grant applications, used by community partners to itemize total program costs and document how UHA grant funds and other funding sources will be allocated.
HRSN Nutrition Service Request Form
Fully fillable Nutrition Request Form for members and providers requesting Health-Related Social Needs (HRSN) nutrition services and related benefits.
HRSN Housing Service Request Form
Use this form to request housing assistance services.
HRSN Home Changes For Health Request Form
Use this form to request a HRSN Home Changes For Health (such as an air conditioner or portable heater).
UHA Information Sharing Authorization Form
This form gives us permission to send details about your HRSN service request to one of our partners.
Verification of Landlord/Tenant Relationship and Rent Owed
Verification form for Umpqua Health Alliance’s Health-Related Social Needs Rental Assistance Program, documenting landlord/tenant relationship and confirming rent owed when no written lease exists.