Lewis P - International Hyperhidrosis Society



| |ICD-10 Codes |

|Primary Focal Hyperhidrosis, unspecified |L74.519 |

|Secondary Focal Hyperhidrosis |L74.52 |

|Generalized Hyperhidrosis |R61 |

Hyperhidrosis Preauthorization Request Form

Patient Name: ________________________________________ Insurance ID: _____________________________

Date: ________________________________________

What areas of the body require treatment?

( Axillary (Underarms) ( Palmar (Hands) ( Plantar (Feet) ( Face/Head ( Groin

( Submammary (Under Breasts) ( Other (Please Specify) _______________________

Hyperhidrosis Disease Severity Scale:

( Sweating is never noticeable & never interferes with daily activities

( Sweating is tolerable and sometimes interferes with daily activities

( Sweating is barely tolerable & frequently interferes with daily activities

( Sweating is intolerable and always interferes with daily activities

Impairment of Daily Activities, & Impact on Quality of Life:

( Work & professional life ( Sexual activities

( Meeting people ( Sports

( Relationships with family & friends ( Clothing/Shoes

( Shaking hands ( Emotional state

( Developing personal relationships ( Education

Previous Treatments:

( OTC Antiperspirants ( Rx Antiperspirants ( Iontophoresis ( BOTOX®

( Oral Medications ( miraDry ( Topical Anticholingeric (Qbrexza™)

( Surgery (Local) ( Surgery (ETS) ( Psychiatric Medications/Care

Recommended Treatment for:

( Axillary (Underarms) ( Palmar (Hands) ( Plantar (Feet) ( Face/Head ( Groin

( Submammary (Under Breasts) ( Other (Please Specify) _______________________

Is/are:

( OTC Antiperspirants ( Rx Antiperspirants ( Iontophoresis ( BOTOX®

( Oral Medications ( miraDry ( Topical Anticholingeric (Qbrexza™)

( Surgery (Local) ( Surgery (ETS) ( Psychiatric Medications/Care

Other: ______________________________________________________________________________________

Notes: ______________________________________________________________________________________

For more information about hyperhidrosis, visit the International Hyperhidrosis Society at .

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