Transcription of Atypical Antipsychotics Coverage Determination …
{{id}} {{{paragraph}}}
Example: biology
Atypical Antipsychotics Coverage Determination …
Atypical Antipsychotics Coverage Determination (FOR PROVIDER USE ONLY) Customer ID:Customer DOB:Customer Address:Phone (Home):Phone (Cell):NPI Number:Provider Name:Provider Address:Drug Name:Dosage:Frequency:Quantity:Refills: New Medication ContinuationProvide Start Date---------> List Diagnosis/ICD-10 codes: Do Not Substitute-Dispense As WrittenProvider Specialty:DRUG & PRESCRIPTION INFORMATION REQUIRED (Please Write Legibly)Provider Phone:Please check whether this is a new medication or therapy continuationProvider Fax:MEMBER INFORMATION REQUIRED (Please Write Legibly)Customer Name:PROVIDER INFORMATION REQUIRED (Please Write Legibly)License Number:DEA Number:Office Contact Name:If you have checked "Continuation", SELECT DIAGNOSISA typical Antipsychotics_FormINT_17_59006 09152017 Page 1 of 2 Atypical Antipsychotics Coverage Determination (FOR PROVIDER USE ONLY) DosageFrequencyQuantityOther Questions:For Aripiprazole and Rexulti: YES NOFor Paliperidone ER tablet: Is the specific diagnosis Schizoaffective Disorder?
Atypical Antipsychotics Coverage Determination (FOR PROVIDER USE ONLY) Dosage Frequency Quantity Other Questions: For Aripiprazole and Rexulti:
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: