Prolia® Insurance Verification Request Form
Please complete this form to the fullest extent possible.
If an item does not apply, please note “N/A” on that line.
Fax with insurance card copies to ProliaPlus®: 1-877-877-6542
Patient Information
Physician Information
*Patient Name:
Attach patient demographic sheet OR Complete information below:
*Street Address:
*City:
*State:
*Zip:
*Telephone:
M
F
*Date of Birth:
Social Security Number:
*Physician Name:
Specialty:
*Site Name:
*Site Street Address:
*City:
*Telephone:
Email address:
Office Contact:
Physician Tax ID #:
*Physician NPI #:
*Site Type:
MD Office
Preferred Fulfillment Option
Step 1: Select only ONE of the following (ProliaPlus® will only process
One option; defaults to physician purchase)
Medical Benefit (Physician Purchase or Specialty Pharmacy)
Injection Network
If preferred location, please list name and phone #:
Pharmacy Benefit
Step 2:
Check here if you would like Prior Authorization support
Primary Insurance Information
*Zip:
Hospital Outpatient
Other
Patient Medical Information
*Please provide one primary ICD-9 Code:†
733.00 Osteoporosis, unspecified
733.01 Senile osteoporosis, postmenopausal osteoporosis
Other (specify ICD-9-CM)
Please provide secondary ICD-9 Code, if applicable:
Additional Information (If PA is Required)
Attach a copy of insurance card, front AND back
OR Complete insurance information below:
*Name of Insurer:
Insurer Telephone:
Subscriber Date of Birth:
*Subscriber Relation to Patient:
Group Number:
*Policy Number:
T-Score (if known):
History of osteoporotic fracture
Yes
No
Not Known
Prior Treatment History (if any):
Generic alendronate
Fosamax® (alendronate sodium)
®
Actonel (risedronate sodium)
Boniva® (ibandronate sodium)
Other
Reason for Discontinuing Previous Osteoporosis Therapy(ies):
Secondary Insurance Information (If Applicable)
Attach a copy of insurance card, front AND back
Contraindications (if any):
Pertinent Medical History (eg, calcium and vitamin D supplementation):
OR Complete insurance information below:
*Name of Insurer:
*Is this a Medigap policy?
*State
: Fax:
†The
Yes
No
Not Known
If yes, please indicate plan letter:
sample diagnosis codes are informational and not intended to be directive or a guarantee of
reimbursement and include potential codes that would include FDA approved indications for Prolia ®.
Other codes may be more appropriate given internal system guidelines, payor requirements, practice
patterns, and the services rendered.
*Insurer Telephone:
Prescription Information
Subscriber Name:
Product Name/Strength:
Prolia® 60 mg pre-filled syringe
Directions: 60 mg SC every 6 months
Refill:
State License:
*Subscriber Relation to Patient:
Group Number:
*Policy Number:
Pharmacy Insurance Information (If Pharmacy)
Attach a copy of insurance card, front AND back OR provide:
*Pharmacy Insurance Patient ID #:
*Pharmacy Insurance Telephone #:
*Asterisk fields are required for processing
Prescriber Signature:
X
Date:
Patient’s Next Appointment Date
If you have any questions, please contact ProliaPlus® at 1-877-776-5421.
Fax Completed Form and/or Copy of Insurance Card(s) to ProliaPlus®: 1-877-877-6542
Prior to transmittal of any personal health information (“PHI”), obtain the legally-required patient authorizations for verification services
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