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7 25-26 weeks of gestation 765. 23 Congenital Abnormality of Respiratory System 748. 3-748. 4 Patient Evaluation Patient s gestational age Required weeks Birth Weight days g/kg/lbs Current Weight Date Recorded ICD-9 Chronic Lung Pulmonary Disease CLD/BPD and less than 24 months at start of RSV Season Yes No Chronic Lung Disease is generally defined For infants 32 weeks Oxygen requirement at 36 weeks gestation age or at discharge. For infants 3...
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How to fill out cvs specialty synagis reorder form
How to fill out CVS Caremark Synagis Prior:
01
Obtain the necessary forms from your healthcare provider or CVS Caremark.
02
Carefully read through the instructions and requirements for filling out the form.
03
Provide your personal information, including your name, address, date of birth, and contact information.
04
Fill in your healthcare provider's information, including their name, address, and phone number.
05
Detail your medical condition or the condition of the individual who will be receiving Synagis.
06
Include any relevant medical history or previous treatments.
07
Provide information on any other medications currently being taken.
08
If applicable, attach any supporting medical documentation or letters from your healthcare provider.
09
Review the completed form to ensure all sections have been filled out accurately and completely.
10
Sign and date the form and follow any instructions for submitting it to CVS Caremark.
Who needs CVS Caremark Synagis Prior:
01
Infants or children at high risk for severe respiratory syncytial virus (RSV) infection may need CVS Caremark Synagis prior.
02
High-risk individuals typically include premature infants, infants with certain heart or lung conditions, and those with weakened immune systems.
03
Your healthcare provider will determine if you or your child meets the criteria for needing CVS Caremark Synagis prior based on the specific risk factors and medical history.
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What is cvs caremark synagis form?
The CVS Caremark Synagis form is a document used to request prior authorization for the medication Synagis (palivizumab), which is administered to prevent respiratory syncytial virus (RSV) infections in high-risk infants.
Who is required to file cvs caremark synagis form?
Healthcare providers, such as physicians or prescribing clinicians, are required to file the CVS Caremark Synagis form on behalf of the patients who need the Synagis medication.
How to fill out cvs caremark synagis form?
To fill out the CVS Caremark Synagis form, you need to provide patient demographics, insurance information, medical history, and indications for the medication, along with supporting clinical documentation if required.
What is the purpose of cvs caremark synagis form?
The purpose of the CVS Caremark Synagis form is to obtain approval from the insurance provider to ensure that the patient is eligible to receive Synagis treatment based on medical criteria.
What information must be reported on cvs caremark synagis form?
The information that must be reported on the CVS Caremark Synagis form includes patient name, date of birth, insurance details, clinical diagnoses, previous medical history, and the specific medical rationale for the use of Synagis.
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