Synagis Statement of Medical Necessity

Providers who wish to administer Synagis in their office are required to submit the Statement of Medical Necessity along with the prior authorization request.

This form applies if billing the Alliance as a medical claim with HCPCS codes. If billing Medi-Cal Rx, refer to www.Medi-CalRx.dhcs.ca.gov.

Haga clic en la imagen debajo para abrir el archivo en PDF: