Connecticut Administrative Code
Title 38a - Insurance Department
504a - Clinical Trials
Section 38a-504a-3 - Request for authorization of coverage
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.
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Section I |
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Date: __________________________________________________________________ |
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Member name: __________________________________________________________ |
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Member ID #: __________________________________________________________ |
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Member Date of Birth: ____________________________________________________ |
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Health Insurer: __________________________________________________________ |
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Treating Physician: ______________________________________________________ |
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Contact Person for Additional Information Regarding Member's Treatment: |
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Name: _________________________________________________________________ |
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Address: _______________________________________________________________ |
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Phone number: __________________________________________________________ |
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Fax number: ____________________________________________________________ |
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E-mail address: _________________________________________________________ |
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Service requested is: ______ Outpatient ______ Inpatient ______ Office Setting |
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If outpatient or inpatient is checked: |
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Facility name & address: ________________________________________________ |
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Clinical Cooperative Group Number: ______________________________________ |
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(Please provide web site addresses or other reference for accessing inforation about this trial.) |
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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. |
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If the clinical cooperative group number is provided above, you do not need to complete Section II. |
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Section II must be completed only if the Clinical Cooperative Gropu Number is unavailable. |
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Section II |
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Diagnosis code: ________________________________________________________ |
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Proposed treatment protocol: ______________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ |
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Phase of clinical trial: ______ I ______ II ______ III |
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Sponsor of clinical trial: __________________________________________________ |
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Clinical Trial has been reviewed and approved by: |
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______ National Institutes of Health |
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______ National Cancer Institute |
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______ Federal Food and Drug Administration |
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______ Federal Dept. of Defense |
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______ Federal Dept. of Veterans Affairs |
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______ Medicare Clinical Trial Policy |
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Check one: ______ Single center study ______ Multiple center study |
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List name(s) and addres(es) of center(s): |
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______________________________________________________________________ |
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______________________________________________________________________ |
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______________________________________________________________________ |
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______________________________________________________________________ |
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______________________________________________________________________ |
