Synagis® Insurance Verification Worksheet
| PATIENT INFORMATION |
||
| Patient’s Name: _____________________ | Date:____________________________ | |
| Medical Record Number: __________________________________________________ | ||
| DOB:___________________________________________________________________ | ||
| Physician:_______________________________________________________________ | ||
| Synagis®(Palivizumab) Indication:_____________________________________________________ | ||
| PROVIDER/ACCOUNT INFORMATION |
|
| Name of account: _____________________ | Type:_________________ |
| Participating Provider number for insurance carrier:_________________________________ | |
| In w hat treatment setting will Synagis® be injected: _________________________________ _________________________________________________________________________ |
|
| INSURANCE INFORMATION |
|
| Insurance Carrier Name:_____________________________________________________ | |
| Insurance ID No.:_______________________ | Insured Group No.:________________ |
| Name of the insured:________________________________________________________ | |
| Insured ID Number:________________________________________________________ | |
| Insurance telephone number:__________________________________________________ | |
| Insurance address:__________________________________________________________ | |
| Contact name:_____________________________________________________________ | |
| Special Instructions for Synagis® Administration: _______________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ |
|
For reimbursement assistance, please contact the Synagis® Reimbursement Hotline at 1-877-633-4411.