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State of Oklahoma SoonerCareAzedra (Iobenguane I131) Prior Authorization Form Member Name:___ Date of Birth:___ Member ID#:___Drug Information Physician billing (HOPES code:___) Start Date (or date
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How to fill out azedra iobenguane i-131 prior
How to fill out azedra iobenguane i-131 prior
01
Obtain a prescription for Azedra iobenguane I-131 from a healthcare provider.
02
Gather all necessary information and medical history to properly fill out the form.
03
Follow the instructions provided by the healthcare provider or the Azedra product information for dosage and administration.
04
Fill out the patient's personal information accurately, including name, date of birth, and contact details.
05
Provide medical information such as current medications, allergies, and any existing medical conditions.
06
Answer the questions regarding the patient's pregnancy status and whether they are breastfeeding.
07
Ensure that all sections of the form are completed thoroughly and legibly.
08
Review and double-check the filled out form for any errors or missing information.
09
Submit the completed form to the appropriate healthcare provider or facility as instructed.
Who needs azedra iobenguane i-131 prior?
01
Azedra iobenguane I-131 is typically used for patients with advanced pheochromocytoma or paraganglioma, who require systemic therapy and have not responded to other treatment options like surgery or radioactive therapy.
02
It is a radioactive therapeutic agent that can be administered to adults and adolescents aged 12 years or older, who meet certain criteria and have been evaluated by a healthcare provider.
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What is azedra iobenguane i-131 prior?
Azedra iobenguane i-131 prior is a form that needs to be filled out prior to receiving the medication Azedra, which contains iobenguane i-131.
Who is required to file azedra iobenguane i-131 prior?
Patients who will be receiving the medication Azedra are required to file azedra iobenguane i-131 prior.
How to fill out azedra iobenguane i-131 prior?
To fill out the form, patients need to provide their personal information, medical history, and consent for treatment with Azedra.
What is the purpose of azedra iobenguane i-131 prior?
The purpose of the form is to ensure that patients understand the risks and benefits of treatment with Azedra, and to obtain their consent before proceeding with the treatment.
What information must be reported on azedra iobenguane i-131 prior?
Patients must report their medical history, current medications, allergies, and any existing conditions that may affect their treatment with Azedra.
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