Form 1312, Growth Hormone Products Authorization Request (CSHCN)

Instructions

Updated: 6/2022

Purpose

Growth hormones are covered for the treatment of people with specific diagnoses involving growth hormone deficiency. If an initial or extension request cannot be approved based on the above criteria, the approval request may be sent for medical review and reconsideration to the Children with Special Health Care Needs (CSHCN) Services Program.

Procedure

When to Prepare or Update

This form is only used for people enrolled in the CSHCN Services Program.

A program-approved prescribing physician must complete and sign this form annually certifying that the individual continues to require these medications.

Requests must be signed and submitted by the prescribing physician. Please complete all requested information or document why information is not available.

Transmittal

Staff sends the form to the CSHCN-enrolled pharmacy, who then forwards the completed form by fax or mail:

Detailed Instructions

1. If a person is enrolled in the CSHCN Services Program, an approved prescribing physician will complete this form.
2. The prescribing physician must supply medical necessity documentation for people with specific diagnoses involving growth hormone deficiency.
3. The prescribing physician must sign and submit the form completing all applicable fields.
4. If information in not available, the prescribing physician must document why the information is not available.
5. Direct all questions about this form to the CSHCN Services Program at 800-252-8023.