Hiv Diagnosis Verification - Prior Authorization Form

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CHILDREN’S MEDICAL SERVICES NETWORK
Prior Authorization
HIV DIAGNOSIS VERIFICATION
This form is not the appropriate form for Fuzeon, Selzentry, or Serostim submissions.
Note: Form must be completed in full. An incomplete form may be returned.
Recipient’s Medicaid ID#
Date of Birth (MM/DD/YYYY)
/
/
Recipient’s Full Name
Prescriber’s Full Name
Prescriber License # (ME, OS, ARNP, PA)
Prescriber Phone Number
Prescriber Fax Number
-
-
Drug
Quantity
Dosage and Frequency of Dosage
HIV Diagnosis Verification
Diagnosis / Indication for therapy:
Maternal-fetal prophylaxis
Sexual Assault (non-occupational exposure prophylaxis)
HIV
(Specify Diagnosis Code): ______________
Pre-Exposure HIV Prophylaxis (complete entire form)
Other: _________________________ (complete entire form)
Patients and providers who call 800-603-1714 or 877-553-7481 to verbally attest to an HIV diagnosis will be allowed a one month override to allow
time for diagnoses codes to be updated in the billing process or for this verification form to be submitted with medical records to Medicaid.
Technology solutions have been implemented to allow claims to automatically process for maternal-fetal prophylaxis and assault victims
Pre-Exposure Prophylaxis (PrEP) for HIV
A detailed plan for preventive or risk reduction services (i.e., evaluation, counseling, condom distribution) must be attached (in the form of
progress notes or medical records) to this submission as per the CDC Guidance or Public Health Service Guidelines for HIV PrEP.
1)
Creatinine Clearance (official test results must be submitted): _____________ mL/min
2)
HIV antibody test (official test results dated within past 90 days must be submitted):
Positive
Negative
3)
Is patient at high risk for acquiring HIV infection?
Yes
No
4)
Date of last sexually transmitted infections (STI) test? _______________
Positive
Negative
5)
If so, what is the current treatment (supporting documentation must be submitted)? ___________________________________
_________________________________________________________________________________________________________
6)
Date of next office visit: ________________________
7)
If this is continuation of therapy, has patient been compliant with PrEP medication?
Yes
No
Prescriber’s Signature: __________________________________________
Date:____________________________
REQUIRED FOR REVIEW: Copies of medical records (i.e., diagnostic evaluations and recent chart notes), a copy of the original
prescription, and the most recent copies of related labs. The provider must retain copies of all documentation for five years.
Fax or mail completed forms to:
Magellan Rx Management
Prior Authorization
P. O. Box 7082
Tallahassee, FL 32314-7082
Phone: (877) 553-7481
Fax: (800) 424-5716

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