Topical Tretinoin Prior Review/certification Faxback Form
ADVERTISEMENT
1Topical Tretinoin
PRIOR REVIEW/CERTIFICATION FAXBACK FORM
INCOMPLETE FORMS MAY DELAY PROCESSING
ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT BCBSNC PROVIDER ID# BELOW
PRESCRIBER NAME
PRESCRIBER NPI [REQUIRED]
BCBSNC PROV ID # / TAX ID [out of state only]
CONTACT PERSON
PRESCRIBER PHONE
PRESCRIBER FAX
PRESCRIBER ADDRESS
CITY
STATE
ZIP
PATIENT NAME
BCBSNC ID
DATE OF BIRTH
GENDER
M
F
Dx Code:_____________
1) For which of the following conditions is the requested tretinoin product being prescribed
Treatment of acne vulgaris
Treatment of actinic keratosis
Treatment of ichthyoses
Treatment of another condition (please describe): ___________________________________________
2) Indicate the drug product being requested and answer the associated questions, if any:
Generic tretinoin or tretinoin combinations
Brand-name Tretinoin or Tretinoin combinations (please check medication requesting):
Atralin
Retin-A
Retin-A Micro
Tretin-X
Veltin
Ziana
a) Has the patient failed treatment with generic tretinoin? ...........................................................
Yes
No
b) Has the patient experienced intolerable side effects with generic tretinoin? ..........................
Yes
No
Please certify the following by signing and dating below:
I certify that I have been authorized to request prior review and certification for the above requested service. I further
certify that my patient’s medical records accurately reflect the information provided. I understand that BCBSNC may
request medical records for this patient at any time in order to verify this information. I further understand that if
BCBSNC determines this information is not reflected in my patient’s medical records, BCBSNC may request a refund of
any payments made and/or pursue any other remedies available.
Prescriber’s Signature (Required):_____________________________________Date:_________________
For BCBSNC members, fax form to 1-800-795-9403
Last Revision Date: 7/2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business