Form FA-65 "Synagis Authorization Request Form" - Nevada

What Is Form FA-65?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 7, 2019;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FA-65 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form FA-65 "Synagis Authorization Request Form" - Nevada

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Nevada Medicaid
rex
Submit fax request to: 855-455-3303
Please note: All information below is required to process this request.
Synagis® Authorization Request Form
for the Nevada Respiratory Syncytial Virus (RSV) season September 1, 2021,
®
For a prescribing physician to request Synagis
®
through March 31, 2022. Synagis
authorization will not be issued for therapy dates in the 2021-2022 season after March 31, 2022.
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED.
Member Information
Provider Information
(required)
(required)
Member Name:
Provider Name:
Insurance ID#:
NPI#:
Specialty:
Date of Birth:
Office Phone:
Street Address:
Office Fax:
City:
State:
Zip:
Office Street Address:
Phone:
City:
State:
Zip:
Medication Information
(required)
Medication Name:
Strength(s) of vial(s) to be
Number of single dose vials (whole
dispensed:
number) for each strength:
Directions for Use:
❑ Check if request is for continuation of therapy
Clinical Information
(required)
Demographics:
Gestational Age: ____________
Weeks: __________
Days: __________ (Both weeks and days are required)
Current Weight: ____________
Date on which current weight was recorded: ___________
If Hospice, list Hospice Diagnosis: _______________________________________________
Please check the applicable boxes to indicate each item as true for the recipient:
Child is <12 months of age at the onset of RSV season on September 1 (born after 09/01/20).
Child is <24 months of age at the onset of RSV season on September 1 (born after 09/01/19).
Child has a diagnosis of chronic lung disease of prematurity (formerly called bronchopulmonary dysplasia).
Child has required medical treatment for chronic lung disease of prematurity in the preceding six months (only
required if child is ≥ 12 months of age). Please check all that apply and document administration dates:
Oxygen
Most recent date administered: __________________________
Corticosteroids
Most recent date administered: __________________________
Bronchodilators
Most recent date administered: __________________________
Diuretics
Most recent date administered: __________________________
Child has hemodynamically significant cyanotic or acyanotic congenital heart disease (CHD)
Please check all that apply, and document medications received or date of surgeries:
Congestive heart failure/cardiomyopathy; Medications: _________________________________________
Moderate to severe pulmonary hypertension; Medications: ______________________________________
Cyanotic heart disease; Medications: _____________________________________________________
Cardiopulmonary bypass surgery and continues to require prophylaxis after surgery or at the conclusion of
extracorporeal membrane oxygenation; Date: ___________________________
Other diagnosis; Document: __________________________ Medications: ________________________
The child has congenital abnormalities of the airways or neuromuscular disease. Document: ___________________
The child has a neuromuscular disease that impairs the ability to clear secretions from the upper airway.
Document diagnosis:__________________________________________________________________
Child has had a cardiac transplant; Date of transplant: _________________________________
Child is severely immunocompromised during the RSV season; Document: ______________________________
Child has cystic fibrosis: (please check all that apply):
Child has clinical evidence of chronic lung disease.
Child has clinical evidence of nutritional compromise.
For children with cystic fibrosis ≥ 12 months of age:
Weight-for-length less than 10th percentile; Length: _______________
Child has had previous hospitalization for pulmonary exacerbation in the first year of life.
Child has abnormalities on chest radiography or chest computed tomography that persists when stable.
FA-65 Updated 09/01/2021 pv08/13/2021
Page 1 of 2
Nevada Medicaid
rex
Submit fax request to: 855-455-3303
Please note: All information below is required to process this request.
Synagis® Authorization Request Form
for the Nevada Respiratory Syncytial Virus (RSV) season September 1, 2021,
®
For a prescribing physician to request Synagis
®
through March 31, 2022. Synagis
authorization will not be issued for therapy dates in the 2021-2022 season after March 31, 2022.
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED.
Member Information
Provider Information
(required)
(required)
Member Name:
Provider Name:
Insurance ID#:
NPI#:
Specialty:
Date of Birth:
Office Phone:
Street Address:
Office Fax:
City:
State:
Zip:
Office Street Address:
Phone:
City:
State:
Zip:
Medication Information
(required)
Medication Name:
Strength(s) of vial(s) to be
Number of single dose vials (whole
dispensed:
number) for each strength:
Directions for Use:
❑ Check if request is for continuation of therapy
Clinical Information
(required)
Demographics:
Gestational Age: ____________
Weeks: __________
Days: __________ (Both weeks and days are required)
Current Weight: ____________
Date on which current weight was recorded: ___________
If Hospice, list Hospice Diagnosis: _______________________________________________
Please check the applicable boxes to indicate each item as true for the recipient:
Child is <12 months of age at the onset of RSV season on September 1 (born after 09/01/20).
Child is <24 months of age at the onset of RSV season on September 1 (born after 09/01/19).
Child has a diagnosis of chronic lung disease of prematurity (formerly called bronchopulmonary dysplasia).
Child has required medical treatment for chronic lung disease of prematurity in the preceding six months (only
required if child is ≥ 12 months of age). Please check all that apply and document administration dates:
Oxygen
Most recent date administered: __________________________
Corticosteroids
Most recent date administered: __________________________
Bronchodilators
Most recent date administered: __________________________
Diuretics
Most recent date administered: __________________________
Child has hemodynamically significant cyanotic or acyanotic congenital heart disease (CHD)
Please check all that apply, and document medications received or date of surgeries:
Congestive heart failure/cardiomyopathy; Medications: _________________________________________
Moderate to severe pulmonary hypertension; Medications: ______________________________________
Cyanotic heart disease; Medications: _____________________________________________________
Cardiopulmonary bypass surgery and continues to require prophylaxis after surgery or at the conclusion of
extracorporeal membrane oxygenation; Date: ___________________________
Other diagnosis; Document: __________________________ Medications: ________________________
The child has congenital abnormalities of the airways or neuromuscular disease. Document: ___________________
The child has a neuromuscular disease that impairs the ability to clear secretions from the upper airway.
Document diagnosis:__________________________________________________________________
Child has had a cardiac transplant; Date of transplant: _________________________________
Child is severely immunocompromised during the RSV season; Document: ______________________________
Child has cystic fibrosis: (please check all that apply):
Child has clinical evidence of chronic lung disease.
Child has clinical evidence of nutritional compromise.
For children with cystic fibrosis ≥ 12 months of age:
Weight-for-length less than 10th percentile; Length: _______________
Child has had previous hospitalization for pulmonary exacerbation in the first year of life.
Child has abnormalities on chest radiography or chest computed tomography that persists when stable.
FA-65 Updated 09/01/2021 pv08/13/2021
Page 1 of 2
Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to
this review?
Please note:
This request may be denied unless all required information is received.
For urgent or expedited requests please call 1-800-711-4555.
This form may be used for non-urgent requests and faxed to 1-800-527-0531.
This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider
named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose
PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using
information in this document is against the law. If you are not the intended recipient, please notify the sender immediately.
FA-65 Updated 09/01/2021 pv08/13/2021
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