Form 3495c - Nutritional Supplement Program Nutritional Service Prior-Authorization Request - Maryland Medicaid Pharmacy Program - 2011

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M
M
P
P
ARYLAND
EDICAID
HARMACY
ROGRAM
PH  1­800­932­3918
O
1­866­440­9345
F
AX 
NUTRITIONAL SUPPLEMENT PROGRAM
NUTRITIONAL SERVICE PRIOR-AUTHORIZATION REQUEST
(To be faxed along with Form 3495)
Date of Request:________________________________
Patient’s Name:______________________________ ___________ MA#:_______________________
Phone:_______________
Provider: ______________________________________________
Phone:______________________ Fax:_________________
*Note: Although nutritional supplements are over-the-counter items, they require a valid prescription. These orders are subject to the
same rules as legend drug prescriptions.
Dispensing Pharmacist Signature Required
I certify that the information presented on this form is correct and that the products were dispensed in the quantity and at the dosage as
stated on the nutritional prescription and Form 3495. All paid claims are subject to post-payment review by the State. Providers are
mandated to reverse any claim that is found to be improperly submitted. All services must be pre-approved by the State.
Prescriber’s Name: ____________________________________________
Degree: _________________________
Address: __________________________________________________________________________________________
Phone: __________________________ Fax: ________________________
Date: ___________________________
Prescriber’s Signature: __________________________________________
NPI # ___________________________
Requested Service PA:
Date of Service:_________________
Rx#____________________
Qty:_________ Day Supply:_________________
Nutritional Product: __________________________________________
NDC #: ___________________________________
For Internal Use:
Approved from:______________ to ______________ Initials:________ Qty:______ Days Supply:_____ Max daily dose:_________
Requested Service PA:
Date of Service:_________________
Rx#____________________
Qty:_________ Day Supply:_________________
Nutritional Product: __________________________________________
NDC #: ___________________________________
For Internal Use:
Approved from:______________ to ______________ Initials:________ Qty:______ Days Supply:_____ Max daily dose:_________
Requested Service PA:
Date of Service:_________________
Rx#____________________
Qty:_________ Day Supply:_________________
Nutritional Product: __________________________________________
NDC #: ___________________________________
For Internal Use:
Approved from:______________ to ______________ Initials:________ Qty:______ Days Supply:_____ Max daily dose:_________
Requested Service PA:
Date of Service:_________________
Rx#____________________
Qty:_________ Day Supply:_________________
Nutritional Product: __________________________________________
NDC #: ___________________________________
For Internal Use:
Approved from:______________ to ______________ Initials:________ Qty:______ Days Supply:_____ Max daily dose:_________
Approved -
Please resubmit claim on-line- Service PA has been issued.
Rejected -
Missing 3495; please refax request with missing document.
Please call 1­800­932­3918 for follow-up questions.
Pending -
Date Processed: ____________
Initials: __________
Form 3495C Revised 03/2011

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