Universal 17-P Authorization Form
*Fax the COMPLETED form OR call the plan with the requested information.
□
□
□
□
Absolute Total Care
BlueChoice HealthPlan
First Choice by Select Health
WellCare Health Plan, Inc.
P: 803-933-3689
P: 866-902-1689
P: 888-559-1010 x51042
P: 888-588-9842
F: 866-918-4451
F: 800-823-5520
F: 866-533-5493
F: 866-354-8709
□
□
Advicare
Molina Healthcare, Inc.
P: 888- 781-4371
P: 855- 237-6178
F: 888- 781-4316
F: 855- 571-3011
Date of Request for Authorization _____________________________
Patient/Member Name _________________________________________________ DOB ___________________
First
Middle
Last
Address (Street, Apt.#) ________________________________________ City/State/Zip _____________________
Phone ______________________ Medicaid Number ____________________ MCO ID Number ______________
□
Pregnancy Information and History
G___ T ___ P ___ A ___ L ___ (Note: A= abortion (spontaneous and medically induced) EDC ________________
Last menstrual period __________ EDD __________ Current Gestational age __________ weeks
□
□
□
□
Bed Rest
Yes
No Experiencing Preterm Labor
Yes
No
(Home administration available if on bed rest)
□
□
Singleton Pregnancy
Multiple Pregnancy
□
□
□
□
At least 16 weeks gestation
Yes
No**
Major Fetal or Uterine Anomaly
Yes
No
□
□
Patient has a history of prior spontaneous singleton preterm birth between 20-36.6 weeks
Yes
No
□
□
Delivery was due to preterm labor or PPROM even if it resulted in C-section
Yes
No
□
□
Delivery was not due to medical indication, e.g. preeclampsia, abruption, etc.
Yes
No
□
Medication Allergies _____________________________________________________
No known drug allergies
Other Pertinent Clinical Information:_______________________________________________________________
___________________________________________________________________________________________
□
Pharmacy Information
□
Ship to patient’s home address
End Date of Service ____________________
□
Ship to provider’s address
End Date of Service ____________________
□
□
□
Shipping Preference:
Regular Mail
Ground
Overnight
Ordering Physician’s Signature: ______________________________ Makena or 17-P Compound _____________
□
Provider Information
Ordering Provider Name____________________________________________
(Please Print)
Ordering Provider NPI __________________________ Tax ID ____________________
Address ______________________________________ City/State/Zip ___________________________________
Phone _______________________________ Fax ________________________________
□
□
□
□
Provider Type:
OB/GYN
Family Medicine
MFM/Perinatology
Other
Practice Name: _______________________________________ Practice NPI: ____________________________
Contact Person: _________________________ Phone: _________________________ ._Fax:
__________________
___________
FOR MCO USE ONLY:
□
□
Approved
Denied Authorization # _____________________ Number of Injections _____________________
Date of Notification to Provider: ________________.Reviewer(s) name & title: _______________________________________
Please note that our review applies only to the authorization of medical necessity and benefit coverage. This authorization
is not a guarantee of
payment unless the member is eligible at the time the services are rendered.
** Prescription may be written prior to 16 weeks, but the vial shipment may be withheld by the pharmacy until the 15th week