Zyclara - Christus Health Plan
Transcription
Zyclara - Christus Health Plan
02/26/2015 Service Authorization CHRISTUS Health Plan (Medicaid) Zyclara (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CHRISTUS Health Plan (Medicaid) at 1-866-255-7569. Please contact CHRISTUS Health Plan (Medicaid) at 1-855-656-0363 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Zyclara (Medicaid). Drug Name (select from list of drugs shown) Zyclara (imiquimod) Quantity Route of Administration Frequency Expected Length of therapy Strength Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: t ICD Code: Please circle the appropriate answer for each question. 1. Is the patient 18 years of age or older? Circle Yes or No Y N [If the answer to this question is no, then no further questions are required.] 2. Does the patient have a diagnosis of actinic keratosis in the last 60 days? Y N Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date