AetnaCignaSecure HorizonsAetna Golden Medicare PlanHealth NetBlue Shield 65 PlusHealth Net Seniority PlusBlue Shield Access PlusHumana Medicare AdvantageCalifornia CarePacifiCareOBreastfeeding Medicine ReferralONutrition Consult for Chronic Disease (CMC)ONON-URGENT for routine, elective servicePatient Name:
LastFirstMIDate of Birth(Mo/Day/Yr)I.D.#Gender: MFOther Insurance?Name of Carrier?Job RelatedMVAAccidentPregnancy ID#TelephoneFaxName of Required? :YesNoName:Name:Tentative Date of Service/Admission:ICD-9 Codes(required)Diagnosis Description:Date of Onset/InjuryCPT/HCPC Codes(required)# of Days/Visits:
REQUEST FOR PRIOR ) 652-2900
Please check Health PlanMRI, MRA, CT & Pet ScansM2A Video Capsule EndoscopyColonoscopy; Upper GI Endoscopy
FAX (559) 224-2405SERVICES REQUIRING PRIOR AUTHORIZATION (please check requested service)Obesity - Referral to General SurgeonObesity SurgeryOut-of-Plan ProviderDME RentalDME Purchase over $200Sleep StudiesSignature of Requesting PhysicianPlastic Surgery ReferralHome Health Home I.V.Cosmetic/Reconstructive SurgeryEndocrinologist Visit (Type II Diabetes)(See reverse side of this form for more information)Infusions - Ambulatory (See reverse side of this ; In-office injectablesRequesting Physician (Please Print)Contact Person in Requesting Provider's OfficeTransplants in conjunction with Health Plan ProgramsDescribe Service to which it is addressed and may contain confidential information.
If the reader of this message is not thei ntended recipient, you are hereby notified that any distribution is strictly prohibited.TYPE OF REQUESTWithin 5 days before the actual date of service, provider MUST confirm that the member's health plan coverage is still in effect
.With theexception of urgent requests, it is recommended that you do not schedule appointments prior to authorization approval.Emergencyservices do not require prior authorization and are reviewed retrospectively for necessity.This message is intended only for the use of theURGENT for acute conditions requiring care within 72 hours or less1
3Asst Surgeon Required?
YesToday's Date:Where will services be rendered?
(provide name of facility, if other than provider office or patient's home)Physician/Provider/Facility RequestedComments:PATIENT INFORMATIONFROM - REQUESTING PHYSICIANTO - WHERE WILL PATIENT RECEIVE SERVICES?CLINICAL INFORMATIONTelephoneEFFECTIVE 01/01/2010Anti-infective AgentsEnzyme Therapy AgentsMonoclonal FabrazymeAntihemophilic Agents Naglazyme Innohep Lovenox Peptide AgentsAntineoplastic AgentsGrowth Hormone Agents Viscosupplementation CytoGam
Actimmune Miscellaneous Agents Alferon-N
Avonex > Humira
KineretOrenciaRemicadeExclusions (does not require prior authorization):
* Re Self-Injectables: *Insulin *Blue Shield
Pharmacy , In-Office Injectables, InfusionsPrior Authorization ListAnticoagulant AgentsImmune GlobulinsRocephin
for Lyme Disease OnlyBebulin VHFactor VIIIFactor IXHumate-PNovosevenProplex TRecombinant Factor VIIIRecombinant Factor Stimulating DrugsWith the exception of the exclusions listed above, self-injectables, infusions and high dollar injectables require prior authorization.This list may not contain every item requiring prior authorization.
Please check with Sant UM staff if you are ordering/administering an infusion, self-injectable or high dollar injectable that is not listed here.Sandostatin LAR 01/01/2010.