Implantable Hormone Pellet Prior Auth - the Culinary Health Fund
Implantable Hormone Pellet Prior Auth - the Culinary Health Fund
Implantable Hormone Pellet Prior Auth - the Culinary Health Fund
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1901 Las Vegas Blvd. So.Suite 101Las Vegas, Nevada 89104-1309(702) 892-7313www.culinaryhealthfund.org<strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> <strong>Prior</strong> <strong>Auth</strong>orization Form – <strong>Implantable</strong> <strong>Hormone</strong> <strong>Pellet</strong>sMember and Physician InformationDateMember NameMember ID NumberMember AgePhysician NamePhysician SpecialtyPhysician AddressPhysician TelephonePhysician Fax/E-mailIndicate medication requested (i.e. Testopel), include dosing & frequency:Please provide diagnosis/physical symptomsbeing treatedICD9/ICD 10 code(s)****ICD9/ICD 10 codes are required to process all requests.**Please provide patient’s heightPlease provide patient’s weightPlease attach applicable lab work, including total testosterone, free testosterone, LH, FSH, or prolactin.**Lab reports are REQUIRED to process all requests.**Previous Medications Used (Please Indicate Dates and Outcome)Gel/TopicalPatchInjectableDate ReviewedApproved/Denied (circle one) ByApproval Expiration DateCommentsFor <strong>Culinary</strong> <strong>Health</strong> <strong>Fund</strong> Use Only
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