Infusion & Injection Therapy Authorization Request Form

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Infusion & Injection Therapy Authorization Request Form
Fax: 313-745-0399
Medical Management Phone: 877-501-0958
Date of Request:
_____________
Member’s Name: ________________________________________________
DOB: ________________
DMC Care ID#: ______________________________
Other Insurance: _____________________________________
Member’s Diagnosis: _____________________________________ ICD-10 Codes: ____________________________
Ordering Physician: ____________________________________ Specialty: ___________________________________
Provider/Facility Name: _______________________________________________________________________________
Contact Person: _______________________________
Phone#: _________________ Fax#: ___________________
NPI #: _______________________________
Provider Tax ID #: ______________________________
*MUST SUBMIT CURRENT CLINICAL & COPY OF SCRIPT
INFUSION/INJECTION
HCPCS CODE
DRUG
QUANTITY
FREQUENCY OF
DATES OF
THERAPY DRUG(S)
DOSAGE
DRUG THERAPY
SERVICE
(DAILY/WEEKLY OR
MONTHLY)
INFUSION THERAPY
HCPCS CODE
QUANTITY OR
FREQUENCY OF DRUG
DATES OF
SERVICES
NUMBER OF
THERAPY
SERVICE
VISITS
(DAILY/WEEKLY OR MONTHLY)
MEDICAL MANAGEMENT USE ONLY:
Denied
Approved:
Notification Date: _________________________
Authorization#: ___________________
Staff Initials: _____________________
Date: ________________
PROVIDER MUST NOTIFY MEMBER: CO- PAYS, COINSURANCE & DEDUCTIBLES WILL APPLY FOR THIS SERVICE
A
D
NOT G
P
. P
D
E
D
S
UTHORIZATION
OES
UARANTEE
AYMENT
AYMENT
EPENDENT ON
LIGIBILITY ON
ATE OF
ERVICE
AUTHORIZATION IS NOT INCLUSIVE OF GAP EXCEPTION
CONFIDENTIALITY NOTICE: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and/or privileged
information. If you are not the intended recipient(s), you are hereby notified that any dissemination, unauthorized review, use, disclosure or distribution of this
communication and any materials contained in any attachments is prohibited. If you receive this message in error, or are not the intended recipient(s), please immediately
notify the sender and destroy all copies of the original message, including attachments.
DMC Care 2016
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