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Request for health plan initial determination clinical trial - initial and bb 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by selecting the type of request: Cancer or Non-Cancer. This helps categorize your submission appropriately.
- Fill in the requesting provider's name, facility/institute name, and contact information including phone and fax numbers.
- Provide details for the trial coordinator and research coordinator, ensuring all contact information is accurate.
- Enter the relevant ICD9 codes and requested CPT codes as required for your specific case.
- Indicate whether you are requesting an expedited review by selecting 'YES' or 'NO'.
- Attach any necessary medical records, including a record of the initial assessment, by checking 'YES' or 'NO' under RECORDS ATTACHED.
- Finally, add any comments that may assist in processing your request before submitting the form.
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