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
HE A LTH CHOICE ® Leading the Way to Quality Care
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
