Hospice Information For Medicare Part D - Gateway Health Plan

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HOSPICE INFORMATION for MEDICARE PART D
SECTION I – INFORMATION TO OVERRIDE A3 REJECT
To: Medicare Part D Plan Information
From: Hospice Provider Information
Plan Name
Hospice Name
PBM Name
Address
Phone #
(
)
-
Phone #
(
)
-
Fax #
(
)
-
Fax #
(
)
-
Secure E-Mail
NPI
Contact Name
Contact Name
Patient Information
Prescriber Information
Patient Name
Prescriber Name
Patient DOB
Prescriber NPI
Patient ID # (HICN)
Practice Name
Admit Date
Practice Address
Discharge Date
Contact Name
Admission or Discharge Update Only
Practice Phone #
(
)
-
Primary Diagnosis
Practice Fax #
(
)
-
Secondary Diagnosis
Hospice Affiliated
YES
NO
Unrelated Diagnosis
Hospice Pharmacy Benefit Manager (PBM) Information
PBM Name
BIN
Cardholder ID
PBM Phone #
(
)
-
PCN
Group ID
Medications Unrelated to Terminal Illness and/or Related Conditions: Prior Authorization Required
Medication Name and Strength
Dosing Schedule
Qty/Month
Rationale to Support the Medication is Unrelated to Terminal Illness
(Optional)
Signature of Hospice Representative or Prescriber Required.
Representative __________________________________________________________________________________ Date_____/______/________
Prescriber ___________________________________________________________________________________ Date_____/______/________
*If the prescriber of the non-covered medication is unaffiliated with the Hospice provider, has the prescriber confirmed with the Hospice
provider that the medication is unrelated to the terminal illness and/or related conditions?
YES
NO
*This fax is intended for the use of the individual or entity to which it is addressed. It contains confidential information that is privileged and
exempt from disclosure under State and Federal law. If you are not the intended recipient, distribution or copying of this communication is strictly
prohibited.

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