CONTAINS CONFIDENTIAL PATIENT INFORMATION
Synagis
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 357-9577
Patient Name: ___________________________________
Patient ID#: ________________________________
9. PHYSICIAN SIGNATURE
____________________________________________________________
__________________________________________
Prescriber or Authorized Signature
Date
Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what
medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting
provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.
Note: Payment is subject to member eligibility. Authorization does not guarantee payment.
The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only
for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other
party unless required to do so by law or regulation.
If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of
these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or
destruction of these documents.
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Blue Cross and Blues Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue
Shield Association. The relationship between BCBSTX and Express Scripts is that of an independent contractor. Express Scripts is a separate company and is the pharmacy
benefits manager for the BCBSTX STAR and CHIP business.
2012 TXWPA14 10/09/2012