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Instructions for Form F-00142 Prior Authorization Drug Attachment for Synagis - Wisconsin
This document contains official instructions for Form F-00142 , Prior Authorization Drug Attachment for Synagis - a form released and collected by the Wisconsin Department of Health Services. An up-to-date fillable Form F-00142 is available for download through this link.
FAQ
Q: What is Form F-00142?A: Form F-00142 is the Prior Authorization Drug Attachment for Synagis in Wisconsin.
Q: What is Synagis?A: Synagis is a medication used to prevent serious lung infections in infants at high risk.
Q: Why do I need to fill out Form F-00142?A: Form F-00142 is required to request prior authorization for Synagis treatment.
Q: What information do I need to provide on Form F-00142?A: You will need to provide your personal information, the infant's information, healthcare provider's information, and clinical justification for the Synagis treatment.
Q: Who is eligible for Synagis treatment?A: Infants at high risk for serious lung infections, such as premature infants or infants with certain medical conditions, may be eligible for Synagis treatment.
Q: How long does the prior authorization process take?A: The length of the prior authorization process can vary, but it is important to submit the form well in advance of the anticipated Synagis treatment start date.
Q: Can I appeal if my prior authorization request is denied?A: Yes, if your prior authorization request is denied, you have the right to appeal the decision.
Instruction Details:
- This 4-page document is available for download in PDF;
- Actual and applicable for the current year;
- Complete, printable, and free.
Download your copy of the instructions by clicking the link below or browse hundreds of other forms in our library of forms released by the Wisconsin Department of Health Services.
Download Instructions for Form F-00142 Prior Authorization Drug Attachment for Synagis - Wisconsin
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