Synagis® Pre-Authorization Worksheet

PATIENT INFORMATION
Date:______________  
Patient/Recipient Name:____________________________________________________
Patient Address:____________________________________________________________
_________________________________________________________________________
Patient Phone #: Home:__________________  
Patient Date of Birth: __________________ Sex: ___________________
Parent Name: __________________________  

INSURANCE INFORMATION
Subscriber/Policy Holder:_______________________________  
Subscriber Address if Different:__________________________________________
_______________________________________________________________________		  
Insurance Company:________________________
 Plan Name: ___________________
Pre-authorization Dept. #: ___________________
 Contact Person: ________________
Subscriber Identification #: __________________ Subscriber Group #: _____________

CLINICAL INFORMATION
____ Hospital Inpatient ____ Hospital Outpatient
____ Physician Office ____ Home Health
Diagnosis: _______________ Previous Treatments: _______________
Requested Injection Series: ____ 1 to 3 months ____ 1 to 6 months ____ Other
Approval: ____ Yes Authorization #: ____ No: ____
Comments:________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

For reimbursement assistance, please contact the Synagis® Reimbursement Hotline at 1-877-633-4411.