Fillable ACA Bowel Prep Prevention Coverage Member Request Form

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ACA Bowel Prep Prevention Coverage Member Request Form

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The ACA Bowel Prep Prevention Coverage Member Request Form form is 1 page long and contains:

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  • 2 check-boxes
  • 12 other fields

Country of origin: OTHERS
File type: PDF

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P
rescriberCertification:IcertifythatIamthephysicianandallinformationprovidedonthisformtobetrueandcorrecttothebestofmyknowledgeandbelief.
Thisdocumentcontainsreferencestobrand‐nameprescriptiondrugsthataretrademarksorregisteredtrademarksofpharmaceuticalmanufacturersnot
affiliatedwithBlueCrossandBlueShield.Yourprivacyisimportanttous.Ouremployeesaretrainedregardingtheappropriatewaytohandleyourprivatehealth
information.
12/2020
.
Date: ____ / ____ / ______
Patient Name:
________________________ / ______ / ___________________________________
First MI Last
Patient Address
: ___________________________________________________________________
Street Address
_________________________________________________________________
City / State / Zip
Patient Date of Birth
: ____ / ____ / ____ Sex: M F
If approved, your $0 prevention benefit override will be applied to one additional claim in the benefit year.
□
Retail Pharmacy
□
Mail Service Pharmacy
___________________________________________________ _____________________ _____________________________________
Physician Name (Print Clearly)
Specialty Physician NPI #
Physician Address:
__________________________________________________________________
Street Address
__________________________________ (______)______________ (______)______________
City / State / Zip Office Phone Office Fax
NOTE: Drug selection and prescribing physician signature must be completed to process this request:
Please select drug requested:
Suprep
Gavilyte-N
Gavilyte-G
Gavilyte-C
Gavilyte-H
TriLyte
PEG-Prep
PEG-3350
PEG-3350/KCL Solution/Sodium
PEG-3350 NASUL C
I attest, as prescribing physician, to ALL of the following:
i. The requested medication is being used for emptying out the bowel before colonoscopy procedure
ii. The procedure is being completed to screen for colon and rectal cancers
_________
__
______________________________ ____ /____ /____
Physician Signature
Date
Send completed form to:
Service Benefit Plan
Attn: Reconsideration
P.O. Box 52080
Phoenix, AZ 85072-2080
FAX: 1-877-378-4727
CARDHOLDER COMPLETES
ACA Bowel Prep
Prevention Coverage
Member Request Form
PHYSICIAN COMPLETES
R
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ACA Bowel Prep Prevention Coverage Member Request Form

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Completed 19 January 2022

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