Conn. Agencies Regs. § 38a-504a-3
Standardized form to request authorization for coverage of routine patient care costs associated with clinical trials required by sections 38a-504f and 38a-542f of the Connecticut General Statutes. The commissioner may request additional information on the standardized form.
| Section I |
| Date: __________________________________________________________________ |
| Member name: __________________________________________________________ |
| Member ID #: __________________________________________________________ |
| Member Date of Birth: ____________________________________________________ |
| Health Insurer: __________________________________________________________ |
| Treating Physician: ______________________________________________________ |
| Contact Person for Additional Information Regarding Member's Treatment: |
| Name: _________________________________________________________________ |
| Address: _______________________________________________________________ |
| Phone number: __________________________________________________________ |
| Fax number: ____________________________________________________________ |
| E-mail address: _________________________________________________________ |
| Service requested is: ______ Outpatient ______ Inpatient ______ Office Setting |
| If outpatient or inpatient is checked: |
| Facility name & address: ________________________________________________ |
| Clinical Cooperative Group Number: ______________________________________ |
| (Please provide web site addresses or other reference for accessing inforation about this trial.) |
| Please Note: You may be asked to provide additional information about the clinical trial or the member's diagnosis and the condition prior to the authorization of this request. |
| If the clinical cooperative group number is provided above, you do not need to complete Section II. |
| Section II must be completed only if the Clinical Cooperative Gropu Number is unavailable. |
| Section II |
| Diagnosis code: ________________________________________________________ |
| Proposed treatment protocol: ______________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ |
| Phase of clinical trial: ______ I ______ II ______ III |
| Sponsor of clinical trial: __________________________________________________ |
| Clinical Trial has been reviewed and approved by: |
| ______ National Institutes of Health |
| ______ National Cancer Institute |
| ______ Federal Food and Drug Administration |
| ______ Federal Dept. of Defense |
| ______ Federal Dept. of Veterans Affairs |
| ______ Medicare Clinical Trial Policy |
| Check one: ______ Single center study ______ Multiple center study |
| List name(s) and addres(es) of center(s): |
| ______________________________________________________________________ |
| ______________________________________________________________________ |
| ______________________________________________________________________ |
| ______________________________________________________________________ |
| ______________________________________________________________________ |
(Adopted effective August 30, 2004; Amended March 4, 2009; Amended July 2, 2012)