Certificate of Medical Necessity

Palivizumab (Synagis®)

Fax this completed Certificate of Medical Necessity form along with other required documentation including NICU discharge summary, physician history/physical, physician progress notes and treatment plan including narrative to: / Statewide Fax Number:1-904-905-9849
Section A

Physician Information

Name:

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BCBSF Number:

/

National Provider Identifier (NPI):

Street Address:

City:

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County:

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State:

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ZIP:

Telephone Number:

/

Fax Number:

Contact Name:

Facility Information

Name:

/

BCBSF Number:

/

National Provider Identifier (NPI):

Street Address:

City:

/

County:

/

State:

/

ZIP:

Telephone Number:

/

Fax Number:

Contact Name:

Member Information

Last Name: / First Name:
Member/Contract Number (alpha and numeric): / Date of Birth: / Age: / Weight:
Section B
ICD-9 Code: / Description:
Yes No N/A Is patient picking up medication at a retail pharmacy?
Yes No N/A Is provider buying the medication and billing BCBSF directly?
Yes No N/A Is provider obtaining medication from Caremark for drug replacement?
This is: an initial request. a continuation of therapy. If continuation, what date was therapy initiated?
Total no. of doses to administer: / Dosing schedule (monthly, every 8 hrs…): / Dosing administration route:
Section C
Patient Date of Birth: / Gestational Age at Birth (weeks/days):
Birth Weight (kg): / Current Weight (kg):
Start Date: / Age at Start Date (years/months):


Complete the appropriate sections based on condition:

Hemodynamically Significant CHD / CHF
Cyanotic heart disease
Acyanotic heart disease / Medications used:
Chronic Lung Disease
(Check all therapies used within last six months) / Details:
Supplemental O2
Bronchodilator(s)
Diuretic(s
Corticosteroid(s)
Hospitalized in last 6 months Dates:
Congenital Disorders
(Check all that apply) / Severe neuromuscular disease that compromises handling of respiratory secretions
Congenital abnormalities of the airway
Risk Factor
(Check all that apply) / Day care attendance
Sibling(s) <5 years of age
NICU History / Synagis dose given in NICU?: Yes, date given: No
Discharge summary attached: Yes No

Comments:

My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.

Ordering Physician’s Signature: / Date:

Certificate of Medical Necessity: Palivizumab (Synagis®) 2