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Get and Sign INTRA ARTICULAR HYALURONAN INJECTIONS PRIOR REVIEW 2014-2022 Form

Get and Sign INTRA ARTICULAR HYALURONAN INJECTIONS PRIOR REVIEW 2014-2022 Form

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Orthovisc Supartz Gel-One Monovisc GenVisc 850 Gel-SYN Diagnosis Code Injection Location Please answer the following questions 1. Prescriber s Signature Required Date For BCBSNC members fax form to 1-800-795-9403 For NC State Health Plan members Member ID YPY fax form to 1-866-225-5258 Last Revision Date 3/2014. Is the patient currently receiving treatment with a non-preferred intra-articular hyaluronan Yes No Effective 1/1/16 Please certify the following by signing and dating below I...
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