Vaccines - Medical Necessity Request Form

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Vaccines – Medical Necessity Request
1. Is the vaccine for a routine vaccination or for travel?
□ Routine
Does the member have any chronic conditions [e.g., Diabetes, Liver Disease, Kidney Disease, Asplenia (does
not have a spleen), HIV/AIDS]? Yes or No
-
If Yes, please list the specific condition(s):
______________________________________________________________________________
Is this a booster or catch-up vaccination? Yes or No
-
If yes,please provide number of doses being
requested________________________________________
How many doses in the schedule or series has the member received in the past?
_________________________________________
What is the vaccine being prescribed for?
□ Job Requirement
- What is the member’s occupation? _________________________________
□ School/College
- Will the member be living in a dormitory? Yes or No
- If applicable, please document if the member will be working/studying in an
environment/facility that would require vaccination (e.g., healthcare, laboratory with
Hepatitis A infected primates, day-care)
______________________________________________________________
□ Other: _______________________________________________________________
□ Travel
Where is the member traveling to? (provide specific country): ____________________________
What is the purpose of this visit? ____________________________________________________
Please complete the following questions for members less than 19 years of age:
1. Does the prescriber's office participate in the Vaccines for Children (VFC) Program? Yes or No
If Yes, is the vaccine covered under the VFC program? Yes or No (Please refer to
)
o If covered, can the vaccine be ordered through the VFC? Yes or No
- If no, why not?
________________________________________________________________________
________________________________________________________________________
If No, please provide the reason why the office does not participate in the VFC*:
___________________________________________________________________________
* Note: Offices may enroll in the NJ VFC program via phone at 609-826-4862.
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 1
Rev. 06/16
HNJH Fax #: 888-567-0681
Page

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