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.
Insurance Verification and Prior Authorization Form Fax with copies of insurance card(s), front and back, to Amgen Assist®: 1-877-877-6542 *Asterisk fields are required for processing. If you have any questions, please contact Amgen Assist® at 1-866-AMG-ASST (1-866-264-2778).
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