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Predetermination Form

For all patient referrals, please complete the online pre-determination form. In separate files please submit the supporting clinical documentation required.

Download blank Sirtex Patient Consent Form.

Should you have any questions, please contact the reimbursement team by phone at 888-4-SIRTEX (474-7839) ext. 717 or email sirtexhelp@sirtex.com. If you are unable to upload the clinical or consent files, please send them via fax to 877-642-7888.


SIR-Spheres® Y-90 resin microspheres Predetermination Form


1
Referring Physician Information

2
Hospital / Treating
Center Information

3
Administering Provider
Information

4
Site Coordinator Information

(what's this?)


5
Patient Information


6
Patient Primary
Insurance Information

7
Patient Secondary
Insurance Information

8
Patient Diagnosis
Primary Diagnosis

Secondary Diagnosis

9
Mapping and Treatment
Mapping & Treatment should not be performed until insurance authorization has been received



(what's this?)


10
Pre-Treatment
Evaluation Codes
Mapping
Imaging

SIR-Spheres® Y-90 Microspheres HCPCS Codes



11
Microspheres
Administration Codes
Authorized User (AU) Codes

Interventional Radiology (IR) Codes

Post-Treatment Imaging




What's this?



File Attachments





(on the next page you will be able to upload documents)



SIR-Spheres® is a registered trademark of Sirtex SIR-Spheres Pty Ltd.

Online pre-determination form
APM-US-374 V1 0320