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This document is a coverage fax-back sheet for Xalkori (crizotinib), a medication used for treating non-small cell lung cancer. It collects patient and prescriber information, and includes criteria
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How to fill out xalkori coverage fax-back sheet
How to fill out Xalkori Coverage Fax-back Sheet
01
Obtain the Xalkori Coverage Fax-back Sheet from your healthcare provider or pharmaceutical company.
02
Fill in the patient's personal information, including name, date of birth, and insurance details.
03
Provide the prescribing physician's information, including name, contact number, and signature.
04
Indicate the diagnosis and medical necessity for Xalkori, along with any relevant medical history.
05
Attach any required supporting documents, such as lab results or previous treatment records.
06
Confirm that all information is accurate and complete before submitting.
07
Fax the completed sheet to the designated insurance company or provider.
Who needs Xalkori Coverage Fax-back Sheet?
01
Patients prescribed Xalkori that require insurance coverage.
02
Healthcare providers who need to document and request coverage for their patients.
03
Insurance companies that manage claims for Xalkori prescriptions.
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What is Xalkori Coverage Fax-back Sheet?
The Xalkori Coverage Fax-back Sheet is a document used to verify insurance coverage for the medication Xalkori, allowing healthcare providers to communicate necessary information to insurance companies.
Who is required to file Xalkori Coverage Fax-back Sheet?
Healthcare providers, such as physicians or pharmacists, are required to file the Xalkori Coverage Fax-back Sheet when seeking insurance approval for Xalkori treatment for their patients.
How to fill out Xalkori Coverage Fax-back Sheet?
To fill out the Xalkori Coverage Fax-back Sheet, providers need to complete the specified fields with relevant patient information, insurance details, and clinical data that supports the need for Xalkori therapy.
What is the purpose of Xalkori Coverage Fax-back Sheet?
The purpose of the Xalkori Coverage Fax-back Sheet is to facilitate the process of obtaining prior authorization from insurance companies for covering the cost of Xalkori medication for eligible patients.
What information must be reported on Xalkori Coverage Fax-back Sheet?
The information that must be reported includes patient demographics, insurance information, diagnosis codes, treatment history, and physician details relevant to the necessity of Xalkori treatment.
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