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Please complete ALL information below and fax your request to 18886715285Humira Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODEDMember
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How to fill out moderate to severe hidradenitis?

01
Gather all necessary medical records and documentation related to the condition.
02
Complete the patient's personal information, including name, date of birth, and contact details.
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Provide a detailed medical history, including any past or current treatments for hidradenitis.
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Describe the severity of the hidradenitis, noting any previous surgeries, hospitalizations, or complications.
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Include relevant laboratory test results, such as tissue cultures or blood tests, if available.
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Document the impact of hidradenitis on the patient's daily life, including any limitations or symptoms experienced.
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Consider including photographs or visual documentation of the affected areas, if applicable.
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If necessary, provide additional information from healthcare professionals involved in the patient's care.
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Check that all sections of the form are completed accurately and legibly.

Who needs moderate to severe hidradenitis?

01
Individuals who are experiencing moderate to severe symptoms of hidradenitis suppurativa.
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Patients who have had limited success with previous treatments or therapies for hidradenitis.
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Individuals who have a history of recurrent abscesses, sinus tracts, or scarring associated with hidradenitis.
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People who are seeking specialized treatment or care for their hidradenitis condition.
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Individuals who want to participate in research studies or clinical trials focused on moderate to severe hidradenitis.
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Moderate to severe hidradenitis is a chronic skin condition characterized by painful lumps, abscesses, and scarring in areas where skin rubs together, such as the armpits, groin, and under the breasts. It is more intense and frequent than mild forms of hidradenitis.
Patients diagnosed with moderate to severe hidradenitis who may be seeking treatment, disability benefits, or accommodations are typically required to file documentation regarding their condition. Healthcare providers may also need to report cases for clinical studies or treatment plans.
To fill out documentation for moderate to severe hidradenitis, patients should include their personal information, details about the diagnosis, severity, symptoms, treatment history, and any relevant medical records. They may also need to complete specific forms provided by healthcare providers or insurance companies.
The purpose of identifying and documenting moderate to severe hidradenitis is to ensure proper medical care, access to treatments, eligibility for disability benefits, and to help in clinical research efforts aimed at improving understanding and management of this condition.
Information to be reported includes the patient's medical history, specific symptoms experienced, frequency and duration of flare-ups, previous treatments and their efficacy, and any impact the condition has on daily life and work capabilities.
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