Ct exception form 2026

1. Click ‘Get Form’ to open the ct exception form in the editor.
2. Begin by entering the Patient Information. Fill in the Patient Name, Date of Birth, and Plan Participant ID Number accurately.
3. Next, provide Prescriber Information. Input your name, phone number, and fax number to ensure proper communication.
4. In Section A, specify the Medication and Dose requested clearly to avoid any confusion.
5. For Section B, enter the Diagnosis along with the corresponding ICD-9 Code to support your request.
6. In Section C, articulate the clinical rationale for requesting an exception based on the provided criteria. Be detailed and specific.
7. Finally, complete Section D with any additional information relevant to the patient’s condition that may assist in processing your request.
8. Sign and date the form at the bottom as a certification of accuracy before submitting it via fax to 1-866-309-2734.

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