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Ct exception form 2026
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- Click ‘Get Form’ to open the ct exception form in the editor.
- Begin by entering the Patient Information. Fill in the Patient Name, Date of Birth, and Plan Participant ID Number accurately.
- Next, provide Prescriber Information. Input your name, phone number, and fax number to ensure proper communication.
- In Section A, specify the Medication and Dose requested clearly to avoid any confusion.
- For Section B, enter the Diagnosis along with the corresponding ICD-9 Code to support your request.
- In Section C, articulate the clinical rationale for requesting an exception based on the provided criteria. Be detailed and specific.
- Finally, complete Section D with any additional information relevant to the patient’s condition that may assist in processing your request.
- 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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