MEMBER INFORMATION
MEMBER NAME:
MEMBER ID: DATE OF BIRTH:
GENDER:
M F O
ADDRESS: CIT Y: STATE: ZIP:
PROVIDER INFORMATION
PROVIDER NAME:
(FIRST & LAST)
NPI NUMBER: SPECIALTY:
CLINIC NAME:
CONTACT:
(NAME & PHONE)
SECURE FAX/EMAIL:
ADDRESS: CIT Y: STATE: ZIP:
SITE OF CARE (SERVICING PROVIDER)
SITE OF CARE: CLINIC/OFFICE (11) HOME (12) *OUTPATIENT HOSPITAL (19 OR 22)
NAME: NPI NUMBER:
CONTACT:
(NAME & PHONE)
SECURE FAX/EMAIL:
ADDRESS: CIT Y: STATE: ZIP:
MEDICATION REQUESTED
SITE OF CARE EXCEPTION REQUESTS: PLEASE ATTACH ANY SUPPORTING CLINICAL DOCUMENTATION SUPPORTING THE EXCEPTION REQUEST.
SITE OF CARE EXCEPTION REQUESTS WITHOUT SUPPORTING DOCUMENTATION WILL BE DENIED.
INITIAL REQUEST
RENEWAL REQUEST SITE OF CARE EXCEPTION REQUEST
DRUG NAME AND STRENGTH: DIAGNOSIS (ICD-10):
HCPCS CODE: BODY SURFACE AREA: HEIGHT: WEIGHT:
DOSING REQUESTED: THERAPY START DATE: THERAPY END DATE:
IS THE PATIENT CURRENTLY BEING TREATED WITH REQUESTED DRUG?
YES NO
IF YES, PLEASE INDICATE DATE TREATMENT BEGAN:
PLEASE LIST ALL OTHER MEDICATIONS THE PATIENT WILL BE TAKING IN COMBINATION WITH THE REQUESTED MEDICATION FOR THIS DIAGNOSIS:
FOR NON-ONCOLOGY OFF-LABEL REQUESTS, PLEASE PROVIDE/ATTACH ANY REFERENCING MEDICAL LITERATURE SUPPORTING THE
OFF-LABEL USE (SEE PHARMACY POLICY PP/O001 OFF-LABEL DRUG USE)
FOR ANTI-NEOPLASTIC/ONCOLOGY REQUESTS, INDICATE NATIONAL COMPREHENSIVE CANCER NETWORK® (NCCN) GUIDELINE/S USED
(TITLE/S, VERSION/S, AND APPLICABLE PAGE/S [AS SPECIFIC AS POSSIBLE
MEDICATIONS TRIED AND FAILED FOR THIS DIAGNOSIS:
1. 2.
3. 4.
Provider Administered Infusion/Injection Medication Authorization Form (Buy & Bill)
12/2020
Attn: Pharmacy Dept. Fax (763.847.4014) All elds required. Incomplete and/or Incorrect forms will be returned.
Please follow-up with Customer Service (800.997.1750 Option #3) for Approval/Denial status of this request.
