Nutritional Supplement Pre-Authorization Form - Maryland Medical ...

MARYLAND MEDICAID PHARMACY PROGRAMPH 1­800­932­3918FAX 1­866­440­9345PRESCRIBER STATEMENT OF MEDICAL NECESSITYNUTRITIONAL SUPPLEMENT PRE-AUTHORIZATION FORMIncomplete forms will be returned for reprocessing1. Patient’s Name:______________________________________________ Phone: _______________________________Patient’s Address:_______________________________________________________________________________________Patient’s Medicaid ID #:_______________________________________ DOB:_________________________________Patient Location: Residence Nursing Home Hospital Date Last Doctor’s Visit:__________________Body Weight: _______kg or _______lb Height: _____ft. ____in. Date Measured:________________________2. Justification for nutritional supplement needa) Diagnosis __________________________________________ Date of onset __________________________b) Does recipient have an inborn error of metabolism? Yes Noc) Is patient currently tube-fed? Yes NoIf partially tube-fed, only amount that is actually tube-fed will be approved. Please check % of tube-feeding:100% 75% 50% 25%