Prior Authorization Request Form
Form must be complete, correct, and legible or the PA process can be delayed.
Use one form per member, please.
5. Indicate the % oxygen received, date received, and the duration of treatment:
6. Indicate if patient is receiving any of the following respiratory support therapies on a daily basis:
Systemic corticosteroids Most recent date:
tics Most recent date:
Bronchodilator Most recent date:
Oxygen Most recent date:
7. Does the patient have a diagnosis of Cystic Fibrosis?
If yes, submit documen
tation of pulmonary and nutritional status
8. Does the patient have any of the following?
Anatomic Pulmonary Abnormality. Please specify:
Neuromuscular Disorder. Please specify:
9. Does the patient have any of the following?
Cancer, receiving chemotherapy
Organ transplant, receiving immunosuppressant therapy
Other medical condition that is severely immunocompromising patient (e.g., Children younger than 24 months who will be profoundly
immunocompromised during the RSV season).
10. Has this patient received a heart transplant?
11. Does patient have he
modynamically significant congenital heart disease?
Acyanotic heart dise
ase Most recent date:
Cyanotic heart disease Specify: Name of Pediatric Cardiologist:
12. Will this patient’s congenital heart disease require cardiac surgery?
13. Please list any medications that may be used:
Most recent date administered:
Diuretic Most recent date administered:
Beta-blocker Most recent date administered:
Most recent date
Other cardiovascular medications. Please
14. Please note any other information pertinent to this PA request:
re (Required) Date
(**On behalf of the Prescriber or Pharmacy Provider, I ** certify that the information stated above is a true statement,
made for the purpose
s of inducing SC Medicaid to offer prescription coverage to this individual for the medication
requested above. I understand that this document and any attached materials will be retained for the purposes of possible
October 8, 2018
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