Sec. 38a-504a-3. Request for authorization of coverage

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):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________