Request for authorization of coverage

Standardized form to request authorization for coverage of routine patient care costs associated with clinical trials required by sections 38a-504f and 38a-542f of the Connecticut General Statutes. The commissioner may request additional information on the standardized form. Section I Date: __________________________________________________________________ Member name: __________________________________________________________ Member ID #: __________________________________________________________ Member Date of Birth: ____________________________________________________ Health Insurer: __________________________________________________________ Treating Physician: ______________________________________________________ Contact Person for Additional Information Regarding Member's Treatment: Name: _________________________________________________________________ Address: _______________________________________________________________ Phone number: __________________________________________________________ Fax number: ____________________________________________________________ E-mail address: _________________________________________________________ Service requested is: ______ Outpatient ______ Inpatient ______ Office Setting If outpatient or inpatient is checked: Facility name & address: ________________________________________________ Clinical Cooperative Group Number: ______________________________________ (Please provide web site addresses or other reference for accessing inforation about this trial.) Please Note: You may be asked to provide additional information about the clinical trial or the member's diagnosis and the condition prior to the authorization of this request. If the clinical cooperative group number is provided above, you do not need to complete Section II. Section II must be completed only if the Clinical Cooperative Gropu Number is unavailable. Section II Diagnosis code: ________________________________________________________ Proposed treatment protocol: ______________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Phase of clinical trial: ______ I ______ II ______ III Sponsor of clinical trial: __________________________________________________ Clinical Trial has been reviewed and approved by: ______ National Institutes of Health ______ National Cancer Institute ______ Federal Food and Drug Administration ______ Federal Dept. of Defense ______ Federal Dept. of Veterans Affairs ______ Medicare Clinical Trial Policy Check one: ______ Single center study ______ Multiple center study List name(s) and addres(es) of center(s): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________