Attention- Deficit Hyperactivity Disorder (Adhd) Quantity Limitation Certification Faxback Form

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ATTENTION- DEFICIT HYPERACTIVITY DISORDER (ADHD)
QUANTITY LIMITATION CERTIFICATION FAXBACK FORM
INCOMPLETE FORMS MAY DELAY PROCESSING
ALL NC PROVIDERS MUST PROVIDE THEIR 5-DIGIT BCBSNC PROVIDER ID# BELOW
PRESCRIBER NAME
PRESCRIBER NPI [REQUIRED]
BCBSNC PROV ID # / TAX ID [out of state only]
CONTACT PERSON
PRESCRIBER PHONE
PRESCRIBER FAX
PRESCRIBER ADDRESS
CITY
STATE
ZIP
PATIENT NAME
BCBSNC ID
DATE OF BIRTH
GENDER
M
F
Please check drug requested below (select only one):
Adderall
Adderall XR
Concerta
Daytrana
DextroStat
Dexedrine
Desoxyn
Focalin
Focalin XR
Intuniv
Kapvay
Metadate CD
Metadate ER
Methylin
Methylin ER
Procentra
Quillivant XR
Ritalin
Ritalin LA
Ritalin SR
Strattera
Vyvanse
Zenzedi
Dx Code: _____________
Dosage Requested: _____________________ Quantity Requested (per day): ____________________
See pages 2-4 for FDA approved labeling dosing which does NOT require review
1. Please list medication(s) the patient previously tried and failed, or had an inadequate response related to this
diagnosis:
_________________________________________________________________________________________
_________________________________________________________________________________________
2. Submit documentation to support Quantity Limit Exception:
(submitted documentation may include documented clinical rationale and/or medical records which
support the length of time the requested dose has been use)
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
Please certify the following by signing and dating below:
I certify that I have been authorized to request prior review and certification for the above requested service(s). I
further certify that my patient’s medical records accurately reflect the information provided. I understand that
BCBSNC may request medical records for this patient at any time in order to verify this information. I further
understand that if BCBSNC determines this information is not reflected in my patient’s medical records, BCBSNC
may request a refund of any payments made and/or pursue any other remedies available.
Prescriber’s Signature (Required):_____________________________________Date:_________________
For BCBSNC members, fax form to 1-800-795-9403
1
November 2014

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