Transcription of Insurance Verification and Prior Authorization Form ...
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Insurance Verification and Prior Authorization Form ...
Prolia 60 mg pre-filled syringe, 60 mg SC every 6 months Refill: x1 x2 x3 x4 Prescriber Signature: (required for legal prescription triage) _____Date: _____Patient s Scheduled Injection Date: (Age-related osteoporosis without current pathological fracture) _____ (Age-related osteoporosis with current pathological ) Please provide complete code Other (specify ICD Code) _____ Please provide secondary ICD Code, if applicable: _____ Original Diagnostic T-Score: _____ T-Score Date: _____ History of osteoporotic fracturePrior Osteoporosis Therapy (if any): Generic alendronate Fosamax (alendronate sodium) Actonel (risedronate sodium) Boniva (ibandronate sodium) Other _____Reason for Discontinuing Previous Osteoporosis Therapy(ies):_____Contraindications (if any):_____Patient is currently taking calcium and vitamin D supplements: Ye s NoCalcium level available: Ye s NoOther pertinent information : _____ The sample diagnosis codes are informational and not intended to be directive or a guarantee of reimbursement and include potential codes that would include FDA approved indications for Prolia.
Attach patient demographic sheet OR Complete information below: *Street Address: _____ ... _____ Patient Information Physician Information (Defaults to Medical Benefit) Medical and Pharmacy Benefit Medical Benefit (Physician Purchase) ... patients should be advised to report new or unusual thigh, hip, or groin pain. Any patient who presents ...
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