№ lp_1_10107
File format: docx
Character count: 2857
File size: 49 KB
Request for prior authorization of treatment with TREMFYA® for the listed patient, including clinical justification and supporting patient history.
Year:
[Insert Year]
Region / City:
[Insert City, State ZIP]
Theme:
Medical Treatment Authorization
Document Type:
Authorization Request
Organization:
[Insert Payer Name]
Author:
[Insert Healthcare Provider’s Name]
Target Audience:
Medical Director or individual responsible for prior authorization
Period of Validity:
[Insert Date Range if Applicable]
Approval Date:
[Insert Date if Available]
Amendment Date:
[Insert Date if Applicable]
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The product description is provided for reference. Actual content and formatting may differ slightly.
Note:
Year
Topic:
Medical Treatment Request
Document Type:
Letter
Author:
[Insert Healthcare Provider’s Name]
Target Audience:
Insurance Company
Year:
2020
Region / City:
Australia
Topic:
Pharmaceutical Benefits Scheme (PBS) listing
Document Type:
Committee Submission
Agency:
PBAC (Pharmaceutical Benefits Advisory Committee)
Author:
Committee Secretariat
Target Audience:
Healthcare professionals, PBAC members
Period of Effect:
From May 13, 2020
Approval Date:
May 13, 2020
Modification Date:
Not specified
Year:
[Insert Year]
Region / City:
[Insert City, State]
Topic:
Medical treatment authorization
Document Type:
Letter
Organization / Institution:
[Insert Institution Name]
Target Audience:
Medical Director / Payer
Period of Effectiveness:
[Insert period if specified]
Approval Date:
[Insert Date]
Amendment Date:
[Insert Date if applicable]
Year:
2020
Region / City:
Australia
Topic:
Pharmaceutical Benefits Scheme (PBS) listing
Document Type:
Committee Submission
Agency:
PBAC (Pharmaceutical Benefits Advisory Committee)
Author:
Committee Secretariat
Target Audience:
Healthcare professionals, PBAC members
Period of Effect:
From May 13, 2020
Approval Date:
May 13, 2020
Modification Date:
Not specified
Year:
[Insert Year]
Region / City:
[Insert City, State]
Topic:
Medical treatment authorization
Document Type:
Letter
Organization / Institution:
[Insert Institution Name]
Target Audience:
Medical Director / Payer
Period of Effectiveness:
[Insert period if specified]
Approval Date:
[Insert Date]
Amendment Date:
[Insert Date if applicable]
Year:
2026
Region / city:
Not specified
Topic:
Guselkumab treatment for pediatric plaque psoriasis
Document type:
Research study
Institution:
Not specified
Author:
Vimal H. Prajapati, Marieke M.B. Seyger, Dagmar Wilsmann-Theis, Erzsebet Szakos, Andrzej Kaszuba, Bart van Hartingsveldt, Meg Jett, Gigi Jiang, Shu Li, Vikash Sinha, Herta Crauwels, Cynthia M.C. DeKlotz, Amy S. Paller
Target audience:
Healthcare professionals, dermatologists
Study period:
Not specified
Date of approval:
Not specified
Date of revisions:
Not specified
Description:
Phase 3, randomized, placebo-controlled study of Guselkumab for pediatric patients with moderate-to-severe plaque psoriasis.
Note:
Year
Organization / Institution:
U.S. Department of Labor, Office of Workers’ Compensation Programs, Division of Energy Employees Occupational Illness Compensation
Year:
2023
Region / City:
United States
Topic:
Medical authorization and billing
Document type:
Official form
Organization / Institution:
Department of Veterans Affairs
Author:
Department of Veterans Affairs
Target audience:
Healthcare providers, Veterans
Period of validity:
From date of issue
Date of approval:
Not specified
Date of amendments:
Not specified
Year:
2023
Region / City:
Iowa, Des Moines
Subject:
Proposal Certification and Authorization to Release Information
Document Type:
Certification Letter
Issuing Organization:
Iowa Workforce Development
Author:
Michael Drottz
Target Audience:
Respondents to RFP 309MD24001
Period of Validity:
N/A
Approval Date:
N/A
Date of Revision:
N/A
Note:
Year
Organization / Institution:
Minnesota Department of Education
Target Audience:
School District Superintendents, Early Education Staff
Year:
2023
Region / City:
United States
Topic:
Personnel vetting, security clearance
Document Type:
Questionnaire, Authorization Form
Agency:
Federal Government
Author:
Unknown
Target Audience:
Individuals undergoing personnel vetting
Period of Validity:
Until termination of affiliation with the Federal Government or position requirement
Approval Date:
Not specified
Amendment Date:
Not specified
Document type:
Access authorization form
System:
Enterprise Income Verification (EIV)
Program area:
Multifamily Housing
Issuing organization:
U.S. Department of Housing and Urban Development
Legal basis:
Paperwork Reduction Act of 1995; Federal Privacy Act
OMB control number:
2502-0204
Purpose:
Initial or reinstated access to the Multifamily EIV system and acknowledgment of Rules of Behavior
Target users:
Multifamily Housing Coordinators and Contract Administrator Coordinators
Submission method:
Fax or email to HUD Multifamily Helpdesk
Access duration:
Up to one year before recertification
Security framework:
HUD Security Program Policy; HUD Handbook 2400.25 Rev. 1
Data sensitivity:
Personally identifiable information
Note:
Year
Theme:
Foster Care, Residential Care
Document Type:
Authorization Form
Organization / Institution:
Texas Department of Family and Protective Services (DFPS)
Target Audience:
Caregivers, Caseworkers
Year:
2026
Region / City:
N/A
Subject:
Prior authorization requirements for lower extremity endovascular procedures
Document type:
Checklist
Organization:
N/A
Author:
N/A
Target audience:
Healthcare providers
Period of validity:
N/A
Approval date:
N/A
Date of amendments:
N/A
Year:
2023
Region / City:
University of Kentucky
Subject:
Research Study Participation
Document Type:
Consent Form
Institution:
University of Kentucky
Author:
Research Team
Target Audience:
Potential research participants
Study Duration:
Variable (hours, days, months, years)
Approval Date:
Not specified
Modification Date:
Not specified
Year:
2014
Region / City:
United States
Topic:
Medication Administration, Medical Authorization
Document Type:
Authorization Form
Organization / Institution:
245D licensed program
Author:
Not specified
Target Audience:
Individuals receiving medication assistance, legal representatives
Period of Validity:
Ongoing
Approval Date:
January 1, 2014
Date of Changes:
Not specified
Note:
Year
Topic:
Research, Health Information, Privacy
Document Type:
Authorization Form
Institution:
University of Miami, Jackson Health Systems
Target Audience:
Participants in Research Studies
Year:
Not specified
Region / City:
Not specified
Subject:
Health research, consent, data sharing
Document type:
Authorization form
Organization / Institution:
Medical College of Wisconsin
Author:
Not specified
Target audience:
Researchers, Institutional administrators
Period of validity:
Not specified
Approval date:
Not specified
Date of amendments:
Not specified
Note:
Year
Organization / Institution:
Oregon State University