Rare Disease Intake Form

Member Information

Has this member been diagnosed with a disease or condition that affects fewer than 200,000 persons in the U.S. and is chronic, serious, life-altering, or life-threatening?

Yes

No

Has this member been diagnosed with a disease or condition on the NIH Genetic Rare Disease List?

Yes

No

Has this member been prescribed a drug for treatment designated as a drug for a rare disease or condition on FDA Orphan Drugs list?

Yes

No

If this member has not been diagnosed with a disease or condition on the NIH Genetic and Rare Diseases list, do all the following apply?

Yes

No

(i) received two or more clinical consultations from a primary care provider or specialty provider that are specific to the presenting complaint;

(ii) has documentation in the enrollee's medical record of a developmental delay through standardized assessment, developmental regression, failure to thrive, or progressive multisystemic involvement; and

(iii) had laboratory or clinical testing that failed to provide a definitive diagnosis or resulted in conflicting diagnoses

Are services to monitor and/or treat a rare disease or condition in progress with a non-network provider?

Yes

No

Does service or drug require prior authorization?

Yes

No

Please follow standard PA process

Your responses do not appear to indicate care related to the diagnosis, monitoring, and treatment of a rare disease or condition.

Please validate before completing this form. Call 844-732-3544 with any questions.

Rare Disease Intake Form

Service Information

Submitting Physician Information

Out of Network Service Clinician

Out of Network Service Facility Site