Shp_20151159 - Prior Authorization Form
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2Prior Authorization Form for the 2015-2016 Synagis® Season
Specialty Pharmacy Name:___________________________
Specialty Pharmacy Phone:___________________________
Today’s Date:________ Date Medication Required:________
Phone: 1-800-218-7453 ext. 22080
|
Fax: 1-866-683-5631
Patient Name:
Physician Name:
Address:
State Lic #
DEA #
City:
State:
Zip:
NPI #
Home Phone:
(
)
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Practice Name/Hospital:
Alt Phone:
(
)
-
Address:
Cell Phone:
(
)
-
City:
State:
Zip:
Date of Birth:
_______/______/______
Physician’s Phone:
(
)
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Allergies:
Physician’s Fax:
(
)
-
County:
Nurse/Key Office Contact:
Direct Ext:
ID#:
Specialization:
History of Pregnancy and Previous Doses:
What was the gestational age at birth? _________weeks__________days
Did the patient have previous doses of Synagis in the NICU or other location?
Yes
No
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❑
If yes, provide location of dose(s): __________________________ date(s) of dose(s):__________________________
Patient Evaluation (Please provide applicable ICD-10 code in question 9):
1. Has the patient had a diagnosis of RSV infection during the current 2015-2016 season?
Yes
No
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❑
2. Does the patient have a diagnosis of Chronic Lung Disease of Prematurity/Infancy?
Yes
No
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❑
3. If the answer to question 2 is yes, then in the last 180 days has the patient had a history of chronic systemic corticosteroid
use, diuretic use, long-term mechanical ventilation, bronchodilator therapy, and or supplemental oxygen >21%?
Yes
No
❑
❑
If yes, please provide details about what was used and date(s) prescribed or used:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
4. Does the patient have a severe congenital abnormality of the airway which compromises handling of lower airway secretions?
Yes
No
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❑
5. Does the patient have a severe neuromuscular disease which compromises handling of lower respiratory secretions?
Yes
No
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❑
6. Does the patient have hemodynamically significant heart disease?
Yes
No
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6a. Does the patient have a diagnosis of heart failure?
Yes
No
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If the answer to question 6a is yes, in the last 60 days were any medications prescribed for heart failure?
Yes
No
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If yes, indicate which medications and date prescribed:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6b. Does the patient have a diagnosis of moderate to severe pulmonary hypertension?
Yes
No
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6c. Does the patient have a diagnosis of cyanotic heart disease?
Yes
No
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❑
SHP_20151159
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