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): |
______________________________________________________________________ |
______________________________________________________________________ |
______________________________________________________________________ |
______________________________________________________________________ |
______________________________________________________________________ |
> 
>