FEP Opdivo PA Request Form

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• Required *

• Enter Patient Information

• Drug Name: *
• Blue KC ID (Not SS#): *
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• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date of Birth: *
• Patient Group ID: *
• ICD-10 Diagnosis Codes: *

  Diagnosis Codes must be 3-8 characters along with decimals

  Codes must be 3 - 8 characters and 2 decimals.
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• Has the patient been using samples? Yes No
• Dose and Directions: *

• Required *

• Enter Provider Information

• Provider ID OR NPI: *
• Provider's Name: *
• Physician's Specialty: *
• Street Address: *
• City: *
• State: *
• ZIP Code: *
• Email Address:
• Phone Number:
  Enter a 10 digit phone number.
• Fax Number:*
  Enter a 10 digit phone number.
• Contact First Name: *
• Contact Last Name: *
• Contact Email Address: *
• Contact Phone Number: *
• Contact Phone Ext:
• Contact Fax Number:*

Has the patient been on Opdivo therapy continuously for the last 4 months, excluding samples?

If you have any additional information pertinent to this patient’s therapy, please specify.

Insert Attachments.

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Checking this box will send a copy of your form to the email address provided.