PRESCRIBER STATEMENT OF MEDICAL NECESSITY



PRESCRIBER STATEMENT OF MEDICAL NECESSITY

NUTRITIONAL SUPPLEMENT PRE-AUTH FORM

Maryland Medicaid - Division of Pharmacy Services

Tel # 410-767-1755 or 1-800-492-5231 Option 3

Fax to: 410-333-5398 (All questions must be answered)

Prescribers: Please complete and sign- Incomplete form will be returned for reprocessing.

1. Patient’s Name________________________________________________Phone # __________________

Patient’s Address_______________________________________________________________________

Patient’s Medicaid ID # ______________________________________Date of Birth:________________

Patient location: ___Residence; ___Nursing Home; ___Hospital- Date of last doctor’s visit:____/____/___

Body Weight:_________Circle kg or lb; Height: ___________ Date measured:______/________/______

2. Justification for nutritional supplement need:

a/ Diagnosis and dates of onset_____________________________________________________________

b/ Does recipient have an inborn error of metabolism? Yes____ No____

c/ Is patient currently tube-fed? Yes___No___If partially tube-fed, only amount that is actually tube-fed

will be approved. Please circle % of tube-feeding: 100%; 75%; 50%; 25%; ................
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