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Forms for Physician Office Use

NODMAR/NOMNC Forms

These forms are for Hospitals, Skilled Nursing Facilities, Comprehensive Outpatient Rehabilitation Facilities, and Home Health Providers. UPMC for Life participating providers must now use the UPMC Health Plan-specific Notice of Discharge & Medicare Appeals Rights (NODMAR) and Notice of Medicare Non-Coverage (NOMNC) forms required by CMS.


Ordering Specialty Medications

  • The CuraScript Specialty pharmacy patient enrollment form can be found below. Please fax this form, the patient's prescription, and a completed prior authorization form (if applicable) to the number located on the enrollment form.
    CuraScript Enrollment Form

  • If you are a UPMC owned physician practice and wish to use Falk Clinic instead of CuraScript to provide your patient's specialty drug, the necessary enrollment form can be found below. Please note the enrollment form and prior authorization form (if applicable) must be faxed to Falk Clinic, not the CuraScript pharmacy.
    Falk Clinic Enrollment Form

Rx Prior Authorization Forms

If you require a prior authorization for a medication not listed here, please contact UPMC Pharmacy Services at 1-800-396-4139.

These forms serve all UPMC Health Plan products unless specified otherwise.


Medicare (UPMC for Life) Specific Prior Authorization Forms


* All of our files are in PDF format

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