17-P Authorization Form - Providers - Prestige Health ... - HIE Networks

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Tax ID: NPI #. Phone: Fax: Address, City, State Zip: Provider Information ... Bedrest: (Home administration of 17-P is a
Time Sensitive

17-P Authorization Information

To submit requests, please fax completed form to 1-855-358-5852 If you have any questions please call 1-855-371-8076

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Provider Information Provider’s Name: Tax ID: NPI # Phone:

Fax:

Address, City, State Zip:

Member Information Member Name:

Medicaid ID Number:

Member DOB:

Phone:

Address, City, State Zip:

Pregnancy Information & History Gravida:

Para:

Abortions: Spontaneous

Pre-term:

Living:

EDC:

Induced

Three consecutive abortions:

Yes

No

Experiencing Preterm Labor:

Yes

No

Bedrest: (Home administration of 17-P is available if patient is on bedrest.)

Yes

No

Medication allergies:

No known allergies:

Other pertinent clinical information:

17-P Criteria and Pharmacy Information Have a history of a previous singleton preterm birth between 20 and 36 weeks (spontaneous and no identifiable cause):

Yes

No

Have a current singleton pregnancy:)

Yes

No

Will be at least 16 weeks of gestation at initiation of therapy:

Yes

No

Major Fetal or Uterine Anomaly:

Yes

No

Will be at least 16 weeks gestation at initiation of therapy:

Yes

No

Pharmacy Ship to patient’s home

End date of service:

Ship to Provider Office

End date of service:

Ship to different location (If shipped to a different provider other than indicated above, please provide address and phone number) Physician Authorizing Signature:

Internal Use Only: 17-P Authorization # ___________________________ Covering dates of service _________ to _________ P2051_1402