Form 410-A - Child Growth Hormone Deficiency Pa Request Form
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1Alabama Medicaid Pharmacy
Child Growth Hormone Defi ciency PA Request Form
FAX: (800) 748-0116
Fax or Mail to
P.O. Box 3210
Phone: (800) 748-0130
H
I
D
Auburn, AL 36832-3210
EALTH
NFORMATION
ESIGNS
PATIENT INFORMATION
Patient name
Patient Medicaid #
Patient DOB
Patient phone # with area code
PRESCRIBER INFORMATION
Prescriber name
NPI #
License #
Address
Phone # with area code
City/State/Zip
Fax # with area code
I certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency. I will be
supervising the patient’s treatment. Supporting documentation is available in the patient record.
Prescribing Practitioner Signature
Date
PHARMACY INFORMATION
Dispensing pharmacy
NPI #
NDC #
J Code
Qty. requested per month
if applicable
Phone # with area code
Fax # with area code
DRUG/CLINICAL INFORMATION
Initial Request Renewal*
Drug Requested _______________ Duration of Therapy _______________
Strength/Quantity ___________________ Daily Dose ______________________ Height __________________
Does the patient have a diagnosis of Growth Hormone Defi ciency and has therapy been approved by a board
certifi ed endocrinologist? Yes No
Has Growth Hormone Defi ciency been confi rmed with Provocative Testing? Yes No
Test 1: Type_____________ Result______________ Date_______________
Test 2: Type_____________ Result______________ Date_______________
Indicate at least one of the measurements below:
Patient’s height in standard deviations below the mean _______________, or
Patient’s midparental height percentile in standard deviations below the mean______________, or
Patient’s height percentile____________________
Is the patient’s growth velocity <25th percentile for bone age? (Must be calculated over a minimum of 6 months)
Yes No
Indicate dates measured: _______________________________________
Does the patient have other documented pituitary hormone defi ciencies? Yes No
If yes, are they being treated appropriately? Yes No
Does the patient have normal thyroid function? Yes No
Has the patient been screened for intracranial malignancy or tumor? Yes No
If a history of malignancy exists, has the patient been free of recurrence for at least the past 6 months? Yes No
Does the patient have any of the following contraindications?
Yes
Proliferative or pre-proliferative diabetic retinopathy
Pseudotumor cerebri or benign intracranial hypertension
Pregnancy
Multiple pituitary hormone defi ciencies Closed epiphyses
No
*For renewal requests, indicate the patient’s growth velocity in cm/year since the patient was initiated on the requested medication. ______________
FOR HID USE ONLY
Approve request
Deny request
Modify request
Medicaid eligibility verifi ed
Comments _________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Reviewer’s Signature
Response Date/Hour
Form 410-A
Alabama Medicaid Agency
Rev. 9-15-12
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