Pharmacy Hemophilia Medical Authorization Member ID* Member DOB* MM slash DD slash YYYY Member Name* First Last Member Phone #Error Message Member Height* Member Weight* Provider InformationNPI (Type I)* Provider Name* Error Message Specialty Contact Name* Phone*Fax*Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Servicing Facility InformationNPI (Type II)* Servicing Facility Name* Error Message Place of Administration*Place of Administration *HomeTreatment CenterHospitalOfficeTax ID* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Clinical InformationICD10 Code*Example ICD 10 Code: Z87.890 Requested J-Code*Example J code: A1234 Drug name and strength* Dose (IU) & frequency* Total # of doses requested* Total units requested* Vial strength Assay available Vials requested Units requested to dispense Total doses/units remaining on hand* Date of Service* MM slash DD slash YYYY Request Type*Request Type *InitialContinuationHemophilia InformationType of Use*Type of Use *EpisodicProphylaxisAcute Bleeding EpisodeDental ProcedureSurgical ProphylaxisSeverity of Disease*Severity of Disease *Mild (6% to 25% factor level)Moderate (1% to 5% factor level)Severe (less than 1% factor level)please indicate factor level and date based on the severityFactor Level and Date* If request is for a procedure, indicate Date of Procedure MM slash DD slash YYYY Was diagnosis confirmed by blood coagulation testing?*Was diagnosis confirmed by blood coagulation testing? *YesNoPlease submit factor levels* Was the patient on a different factor product before?*Was the patient on a different factor product before? *YesNoPlease explain* Does the patient have inhibitors to factor products?*Does the patient have inhibitors to factor products? *YesNoPlease document inhibitors* Has the patient previously received Immune Tolerance Induction (ITI)?*Has the patient previously received Immune Tolerance Induction (ITI)? *YesNoPlease indicate dates and duration* Has the patient experienced at least two documented episodes of spontaneous bleeding into the joints?*Has the patient experienced at least two documented episodes of spontaneous bleeding into the joints? *YesNoDoes this patient have minimal treatment exposure (less than 50 exposure days to factor products)?*Does this patient have minimal treatment exposure (less than 50 exposure days to factor products)? *YesNoPlease explain* Please indicate how often inhibitor testing will be performed* Has a pharmacokinetics (PK) test been performed for this patient?*Has a pharmacokinetics (PK) test been performed for this patient? *YesNoDoes the patient have a diagnosis of Glanzmann Thrombasthenia?Does the patient have a diagnosis of Glanzmann Thrombasthenia?YesNoHas the patient tried platelet transfusions?*Has the patient tried platelet transfusions? *YesNoDate of transfusion* MM slash DD slash YYYY Response of transfusion* Does the patient have a diagnosis of Von Willebrand Disease (VWD)?Does the patient have a diagnosis of Von Willebrand Disease (VWD)?YesNoHas the patient tried desmopressin?Has the patient tried desmopressin?YesNoPlease document if there's a contraindication Acute Bleeding SummaryIf applicable Number of bleeds in the past 12 months* Start date of bleed(s) MM slash DD slash YYYY End date of bleed(s) MM slash DD slash YYYY Intensity of bleed(s)Intensity of bleed(s)MildModerateSevereLocation of bleed(s)* # of doses used* CAPTCHA