Connecticut Administrative Code › Title 38a - Insurance Department › 504a - Clinical Trials › Section 38a-504a-3 - Request for authorization of coverage

Current through July 10, 2024
Standardized form to request authorization for coverage of
				routine patient care costs associated with clinical trials required by sections
				38a-504f
				and
				38a-542f
				of the Connecticut General Statutes. The commissioner may request additional
				information on the standardized form.
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):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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