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UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM RELIANT (tofacitnib) Patient name: Medicaid ID #: Prescriber Name: Prescriber NPI#: Contact person: Prescriber Phone#: Extension/Option:

How to fill out history of treatment failure

Following are the steps to fill out history of treatment failure:

1. Begin by gathering necessary information: Collect all relevant medical documents, including previous treatment records, medications used, and any test results related to the failed treatment.
2. Include detailed information about the failed treatment: Provide specifics about the type of treatment received, such as the name of the medication or therapy, dosage, duration, and frequency.
3. Describe the reasons for treatment failure: Document any adverse reactions, side effects, or complications experienced during the treatment. Include information about any necessary adjustments made to the treatment plan or dosage due to these issues.
4. Mention any alternative treatments attempted: If any alternative or complementary treatments were pursued after the initial failure, outline them in detail. Include information about their effectiveness or any reasons for discontinuation.
5. Provide a timeline of treatment history: Chronologically organize the events related to the failed treatment, starting from the initial consultation and progressing through each phase of the treatment. Include dates, healthcare providers involved, and any relevant hospitalizations or emergency visits.
6. Detail any non-medical factors: In some cases, treatment failure may be influenced by non-medical factors like lifestyle choices, non-compliance with prescribed medications, or substance abuse issues. If applicable, include these details while maintaining patient confidentiality.
7. Consult with the healthcare provider: If uncertain about any specific details or unsure how to accurately complete the history of treatment failure, seek guidance from the healthcare provider involved in the treatment. They will provide the necessary support and clarification.

Who needs history of treatment failure?

1. Healthcare providers: Other physicians or healthcare professionals involved in the patient's care may require the history of treatment failure to gain insights into previous treatment attempts, possible underlying conditions, or medication reactions.
2. Future treating physicians: When changing healthcare providers or seeking a second opinion, having a comprehensive history of treatment failure can assist future physicians in making informed decisions about alternative treatments or approaches.
3. Researchers and specialists: Researchers studying specific conditions or treatment modalities may find history of treatment failure valuable in analyzing patterns, identifying potential breakthroughs, or recommending improvements to existing therapies.

In conclusion, filling out the history of treatment failure requires gathering relevant information, describing the failed treatment, documenting reasons for failure, including alternative treatments attempted, creating a timeline, and considering non-medical factors. This information can be crucial for healthcare providers, future treating physicians, and researchers seeking to understand the patient's medical journey and improve treatment outcomes.

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What is history of treatment failure?

History of treatment failure is a record of past unsuccessful attempts or experiences related to medical treatments.

Who is required to file history of treatment failure?

Patients or healthcare providers are typically required to file a history of treatment failure.

How to fill out history of treatment failure?

History of treatment failure can be filled out by providing detailed information about the unsuccessful treatments or therapies, including dates, types of treatment, and outcomes.

What is the purpose of history of treatment failure?

The purpose of history of treatment failure is to assist healthcare providers in making informed decisions about future treatment options.

What information must be reported on history of treatment failure?

Information such as dates of treatment, types of treatment, reasons for failure, and any relevant medical records must be reported on history of treatment failure.