1. No category

02/26/2015
Service Authorization
CHRISTUS Health Plan (Medicaid)
Zyclara (Medicaid)
This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CHRISTUS Health Plan (Medicaid) at 1-866-255-7569.
Please contact CHRISTUS Health Plan (Medicaid) at 1-855-656-0363 with questions regarding the prior authorization process.
When conditions are met, we will authorize the coverage of Zyclara (Medicaid).
Drug Name (select from list of drugs shown)
Zyclara (imiquimod)
Quantity
Route of Administration
Frequency
Expected Length of therapy
Strength
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
Prescribing Physician
Physician Name:
Physician Phone:
Physician Fax:
Physician Address:
City, State, Zip:
Diagnosis:
t
ICD Code:
Please circle the appropriate answer for each question.
1. Is the patient 18 years of age or older?
Circle Yes or No
Y
N
[If the answer to this question is no, then no further
questions are required.]
2. Does the patient have a diagnosis of actinic keratosis in
the last 60 days?
Y
N
Comments:
I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature
Prescriber (Or Authorized) Signature
Date
Date