Cigna Prior Auth Form ≡ Fill Out Printable PDF Forms Online

Question	Answer
Form Name	Cigna Prior Auth Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	cigna botox prior authorization form pdf, cigna botox auth form, cigna prior authorization forms, cigna botox form

Form Preview Example

Pharmacy Services

Phone: (800)244-6224

Fax: (800)390-9745

CIGNA HealthCare Prior Authorization Form

- Botox (botulinum toxin type A) -

Notice: Failure to complete this form in its entirety or include chart notes may result in delayed

processing or an adverse determination for insufficient information.

PROVIDER INFORMATION

PATIENT INFORMATION

* Provider Name:					**Due to privacy regulations we will not be able to respond via

					fax with the outcome of our review unless all asterisked (*)
Specialty:		* DEA or TIN:
Specialty:		* DEA or TIN:			items on this form are completed**
					items on this form are completed**

Office Contact Person:					* Patient Name:

Office Phone:					* CIGNA ID:

Office Fax:					* Date Of Birth:

* Is your fax machine kept in a secure location?			Yes	No	* Patient Street Address:
* Is your fax machine kept in a secure location?			Yes	No
* May we fax our response to your office?			Yes	No

Office Street Address:					City	State	Zip

City	State		Zip		Patient Phone:

Medication requested:

Botox 100 unit vial
Dose and Quantity:	Duration of therapy:	J-Code:	CPT Code:

In what location(s) of the body will Botox injections be given (please specify how many units are being injected into each muscle and how often they will be given)?

Where will this medication be obtained?

CIGNA Tel-Drug (CIGNA's nationally preferred specialty pharmacy)

Retail pharmacy

Prescriber’s office stock (billing on a medical claim form)

Home Health / Home Infusion vendor

Other (please specify):

Please indicate the condition Botox is being used to treat and answer additional questions as necessary. Please include all applicable chart notes with this form.

Blepharospasm

Cervical dystonia, including spasmodic torticollis

Additional

Is the patient’s condition causing persistent pain or interfering

Answer/Detail:

Question(s)

with the patient's ability to perform age-related activities of

daily living?

Focal hand dystonia (e.g., writer's cramp)

Additional	Is the patient’s condition causing persistent pain or interfering	Answer/Detail:
Question(s)	with the patient's ability to perform age-related activities of
	daily living?

Adductor spasmodic dysphonia/laryngeal dystonia

Jaw-closing oromandibular dystonia

Additional	Is the patient’s condition causing persistent pain, interference	Answer/Detail:
Question(s)	with nutritional intake (e.g., masticatory dysfunction that
	results in weight loss or malnutrition), or significant speech
	impairment/interference with the ability to communicate
	effectively?

Meige's syndrome/cranial dystonia (i.e., blepharospasm with jaw-closing oromandibular cervical dystonia)

CIGNA HealthCare Prior Authorization Form – Botox – Page 1 of 3

Additional Question(s)

Is the patient’s condition causing persistent pain, interference with nutritional intake (e.g., masticatory dysfunction that results in weight loss or malnutrition), or significant speech impairment/interference with the ability to communicate effectively?

Answer/Detail:

Spasticity due to cerebral palsy (including spastic equinus foot deformities)

Additional Question(s)