*
*
5
“waiting” patients.
Recipient’s Medicaid ID#
Recipient’s Full Name
Prescriber’s Full Name
Prescriber’s NPI
Prescriber Phone Number
Prescriber Fax Number
Pharmacy Name
Pharmacy Fax Number
Pharmacy Phone Number
Pharmacy Medicaid Provider #
1. lbs kgs
Reset Form Print Form
SPECIALTY MEDICATION
PRIOR AUTHORIZATION FORM
Complete this form and send information to
Sunshine Health Pharmacy Department at (866) 351-7388
For questions, please call 866-796-0530, Ext 41919
Synagis®
Weight Change Form
Note: Form must be completed in full. An incomplete form may be returned.
Any dosage increase must have corresponding weight charts and/or progress notes with current weight.
If the dose needed is less than 5 mg over the approved vial size, round down to the nearest vial size. If the dose needed is
over the approved vial size, then the new vial size will be approved. For those patients who are expected to gain enough weight to
need an additional vial, please schedule a visit to obtain weight & receive approval for dose increase prior to the Synagis®
administration date. There are no immediate approvals
In cases where immediate administration of medication is required, providers should use the currently authorized vial size(s), then
submit a weight change request, which will be applied to subsequent dosages only.
Recipient Date of Birth (MM/DD/YYYY)
/ /
Recipient
Prescriber Phone Number Prescriber Fax Number
- -
Pharmacy Name
Pharmacy Medicaid Provider #
Pharmacy Phone Number Pharmacy Fax Number
- -
1. Previous Weight: _______________ lbs
or
or _______________ kgs
2. Current Weight: _______________
lb
s
or _
______________ kgs
3. New Dose Required: _____________________________________________
Date:
REQUIRED FOR REVIEW: Copies of medical records (i.e., diagnostic evaluations and recent chart notes), and the most recent copies of related labs
The provider must retain copies of all documentation for five years.
In cases where immediate administration of medication is required, providers should use the currently authorized vial size(s), then
Prescriber’s Signature:
*
> mg
for
