Prior Authorization Request Form - Pediatric Growth Hormone

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PRIOR AUTHORIZATION REQUEST FORM
Fax Completed Form to:
SD DEPARTMENT OF SOCIAL SERVICES
866-254-0761
MEDICAL SERVICES DIVISION
For questions regarding this
Prior authorization, call
866-705-5391
PEDIATRIC GROWTH HORMONE
Please fill out form completely (Note: if this is a renewal request, please
include height chart and documentation regarding efficacy with the request)
Part I: RECIPIENT INFORMATION (To be completed by physician’s representative or pharmacy):
RECIPIENT NAME:
RECIPIENT
MEDICAID ID NUMBER:
RECIPIENT DOB:
Part II: PHYSICIAN INFORMATION (To be completed by physician’s representative or pharmacy):
PHYSICIAN
PHYSICIAN NAME:
DEA NUMBER:
Is prescribing physician board certified
endocrinologist or nephrologist?
PHONE:
FAX:
YES
NO
Part III: TO BE COMPLETED BY PHYSICIAN:
REQUESTED DRUG:
Requested Dosage: (must be completed)
Diagnosis for this request:
INITIAL REQUEST
RENEWAL REQUEST
QUALIFICATIONS FOR COVERAGE:
:
(Renewal requests do NOT need to answer the questions below, please submit height chart and documentation of efficacy)
For Growth Hormone Deficiency (please submit either IGF-1 level OR provocative testing results):
IGF-1 Level:_________________
Provocative testing: Type______________________Results_______________________Date________________________
Has the patient been screened for intracranial malignancy or tumor?
YES
NO
For GHD AND Chronic Renal Insufficiency:
Is the patient’s height value or growth velocity less than 2 standard deviations below the mean for age and/or Tanner Stage?
YES
NO
For Idiopathic Short Stature and SGA:
Please indicate patients height or include chart documentation:
Please indicate patient’s predicted height:
For All Patients:
Does the patient have any of the following contraindications? Check all that apply.
Benign intracranial hypertension
Closed epiphyses
NONE
Physician signature:
Date:
Part IV: PHARMACY INFORMATION
SD MEDICAID
PHARMACY NAME:
PROVIDER NUMBER:
PHONE:
FAX:
DRUG NAME:
NDC#:

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