Transcription of SERVICE REQUEST FORM Connect
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SERVICE REQUEST FORM Connect
Patient:6. DIAGNOSIS AND THERAPY INFORMATION5. PRIOR AUTHORIZATION ASSISTANCE Please provide chart notes or other clinical information for PA INFUSION FACILITY INFORMATIONP rimary Diagnosis: Chronic Gout without tophi Chronic Gout with tophi Other Patient cannot take xanthine oxidase inhibitors due to contraindication or hypersensitivity reaction Patient s current oral treatment with xanthine oxidase inhibitors has failed to normalize serum uric acid and signs and symptoms are inadequately controlled despite receiving maximum medically appropriate dose of oral urate-lowering therapy (ULT)Gout medications previously tried and failed, with reason for discontinuation: (Provide the information below or include chart notes containing the required information.)Medication, dose Reason Start Date End Date1 2 3 3.
Page 3 of 4 SERVICE REQUEST FORM KRYSTEXXAConnect Please fax completed form with a copy of the front and back of the patient’s insurance card. Fax: 1-877-633-9522 • Phone: 1-877-633-9521 • Monday–Friday, 8:00 am–8:00 pm ET I hereby authorize my healthcare providers, my health insurance carriers, and my pharmacies to use and disclose my individually identifiable health
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