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Prior-authorization-form-infusion-authorization-mapa - Form_infusion authorization

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Phone:
Fax:
Web Portal:
AUTHORIZATION REQUEST FOR INFUSION SERVICES
**When requesting services, please fax all clinical with supporting medical necessity documentation with this request
to the above listed fax number. Please attach a copy of the physician’s order to the request.
Please PRINT:
Vendor Name: Referral Date:
Contact Person: Phone: Fax:
Ordering Physician: Phone: Fax:
Member Name: ID#: DOB:
Member phone Number: Allergies:
Caregiver’s Name: Relationship: Phone:
Initial Start of Therapy Date: Member’s Height: Weight:
Current Order Start Date: Current Order End Date:
Primary Diagnosis Code: Secondary Diagnosis Code:
Additional Diagnosis:
Previous Authorizations Associated With This Order:
Mental Status
Please complete the following:
€ Oriented € Forgetful € Disoriented € Agitated  € Depressed  € Lethargic  € Comatose € Other
**Please note that the number of units entered must correspond to the dosage prescribed by the physician and the
number of vials used in treatment. Cigna-HealthSpring
®
reimburses infusions costs based on the physician’s order.
Medication Name
Dosage
Route
Frequency
# Units
INT_14_16656 04012014 © 2014 Cigna
888-454-0013
800-831-0145
www.cignahealthspring.com/HSConnect
Nursing, Supplies and Supporting
Equipment for delivery of medications
HCPCS
# Units
Rental or Purchase
Special Instructions Associated With This Order
Care Giver Support and/or Social Issues Complicating Care
Comments
Please provide additional details:
Is the current clinical information provided with this referral? Yes No
**Please note that clinical information must be dated and signed by a physician within the last 60 days.
Clinician’s Signature: Date:
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Prior-authorization-form-infusion-authorization-mapa - Form_infusion authorization

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Completed 2 July 2020

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