Request for health plan initial determination clinical trial - initial and bb 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by selecting the type of request: Cancer or Non-Cancer. This helps categorize your submission appropriately.
  3. Fill in the requesting provider's name, facility/institute name, and contact information including phone and fax numbers.
  4. Provide details for the trial coordinator and research coordinator, ensuring all contact information is accurate.
  5. Enter the relevant ICD9 codes and requested CPT codes as required for your specific case.
  6. Indicate whether you are requesting an expedited review by selecting 'YES' or 'NO'.
  7. Attach any necessary medical records, including a record of the initial assessment, by checking 'YES' or 'NO' under RECORDS ATTACHED.
  8. Finally, add any comments that may assist in processing your request before submitting the form.

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