1. (a) Any provider (physician, hospital, dentist) rendering services to a patient with one of the named disorders may request reimbursement services through the Sickle Cell Syndrome Program. The request shall be made by completing the appropriate program authorization request form. The form shall include:

   1. (1) biographical data of patient;
   2. (2) diagnoses (primary and secondary);
   3. (3) provider information including service date(s);
   4. (4) request and describe service;
   5. (5) describe and justify treatment or service, list other providers and state drug information if applicable;
   6. (6) check number services provided for ambulatory visits and answer all questions pertaining to patient's treatment and financial support; and
   7. (7) signature of physician or dentist, address and date of request.
2. (b) A financial eligibility form shall be submitted in accordance with rules found in 10A NCAC 45A.

History Note: Authority G.S.130A-129;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. July 1, 1982; April 1, 1982;
Temporary Amendment Eff. June 19, 1996;
Temporary Amendment Expired on March 11, 1997;
Amended Eff. August 1, 2000;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 6, 2016.