IVIG Prior Authorization Request Form
Use this form to request insurance prior authorization for IVIG treatment and provide the clinical details needed for review.
Patient Information
First Name
*
Last Name
*
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Insurance Member ID
Treating Provider Information
Treating Provider Name
*
First Name
Last Name
Practice/Clinic Name
*
Specialty
*
Please Select
Allergy & Immunology
Hematology
Neurology
Rheumatology
Internal Medicine
Pediatrics
Other
Office Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Office Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Office Email
*
example@example.com
NPI Number
Authorization Request Details
Diagnosis / Condition Being Treated
*
ICD-10 Code
Medical Necessity Summary
*
IVIG Product Requested
*
Please Select
Gamunex-C
Gammagard Liquid
Privigen
Octagam
Panzyga
Flebogamma DIF
Bivigam
Other
Dosage
*
Unit
*
Please Select
g
mg
mL
Frequency
*
Please Select
Once
Daily
Every 2 Days
Weekly
Every 2 Weeks
Monthly
As Needed
Other
Route of Administration
*
Please Select
Intravenous
Subcutaneous
Other
Requested Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested End Date or Number of Doses
*
Please Select
End Date
Number of Doses
Site of Service
*
Please Select
Inpatient
Outpatient Hospital
Physician Office
Home Infusion
Ambulatory Infusion Center
Other
Request Type
*
Initial Authorization
Renewal
Prior Treatment and Clinical History
Prior therapies tried
*
Corticosteroids
Immunosuppressants
Plasma exchange
Antibiotics
Other
Response to prior therapies
*
Improved
Partially improved
No response
Worsened
Not applicable
Relevant lab or test results summary
History of adverse reactions or contraindications to IVIG
Prior infusion reaction
Severe allergy to IVIG components
Renal impairment
Thromboembolic history
Aseptic meningitis
Other
Hospitalization or recent exacerbations related to condition
*
No recent hospitalization or exacerbation
Recent exacerbation without hospitalization
Hospitalized within the past 12 months
Multiple recent hospitalizations
Supporting Documents and Submission Notes
Supporting documents
*
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Additional comments or payer-specific instructions
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