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Continuation Growth Hormone
Prior Authorization Form
Member Name:
START HERE
Member &
Prescriber
Information
Prescriber Name:
Prescriber Specialty:
Endocrinologist or
nephrologist must be
involved
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How to fill out continuation growth hormone prior
How to fill out continuation growth hormone prior:
01
Obtain the continuation growth hormone prior form from your healthcare provider or pharmacy.
02
Fill out your personal information accurately, including your name, date of birth, and contact information.
03
Provide details about your medical history and any previous use of growth hormone therapy.
04
Indicate the dosage and frequency of your current growth hormone treatment.
05
Include any changes or adjustments to your treatment plan, if necessary.
06
Sign and date the form to confirm your consent and understanding of the continuation growth hormone therapy.
Who needs continuation growth hormone prior:
01
Individuals who have been prescribed growth hormone therapy by their healthcare provider.
02
Patients who have completed an initial evaluation and have shown positive response and benefits from growth hormone treatment.
03
Patients who require ongoing management of growth hormone deficiencies or conditions, such as short stature or growth hormone deficiency.
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