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Preauthorization Request Form

This Hyperhidrosis Preauthorization Request Form may be downloaded and used to notify an insurance organization that you’ve been diagnosed with hyperhidrosis and to demonstrate the degree to which your life is negatively affected by excessive sweating. There is also space on the form for your physician to note hyperhidrosis treatments that you’ve already tried and the next treatment that he or she is recommending. The form should be completed and submitted to the appropriate health insurance organization by your treating physician. You can help your doctor by printing the form and taking it to your next appointment.

ICD-9 Codes:
Primary Focal Hyperhidrosis 705.21
Secondary Focal Hyperhidrosis 705.22
Generalized Hyperhidrosis 780.8

Hyperhidrosis Preauthorization Request Form

Patient Name: ______________________________________________________________________

Insurance ID: ______________________________________________________________________

Date: __________________________


What area(s) of the body require treatment?

__Axillary (Underarms)

__Palmar (Hands)

__Plantar (Feet)

__Craniofacial (Face/Head)

__Submammary (Under Breasts)

__Groin

__Other (please specify):________________________

Hyperhidrosis Disease Severity Scale:

__Sweating is never noticeable & never interferes with daily activities

__Sweating is tolerable and sometimes interferes with daily activities

__Sweating is barely tolerable & frequently interferes with daily activities

__Sweating is intolerable and always interferes with daily activities

Impairment of Daily Activities, & Impact on Quality of Life:

__Work & professional life

__Sexual activities

__Meeting people

__Sports

__Relationships with family & friends

__Clothing/Shoes

__Shaking hands

__Emotional state

__Developing personal relationships

__Education

Previous Treatments:

__OTC Antiperspirants

__Rx Antiperspirants or Clinical Strength Antiperspirants (used as directed)

__Iontophoresis

__BOTOX®

__Surgery (Local)

__Surgery (ETS)

__miraDry®

__Oral Medications

__Psychiatric

__None

Recommended Treatment for:

__Axillary (Underarms)

__Palmar (Hands)

__Plantar (Feet)

__Craniofacial (Face/Head)

__Submammary (Under Breasts)

__Groin

__Other (please specify):________________________

IS/ARE

__OTC Antiperspirants

__Rx Antiperspirants or Clinical Strength Antiperspirants (used as directed)

__Iontophoresis

__BOTOX® 

__Surgery (Local)

__Surgery (ETS)

__miraDry®

__Oral Medications

Other: ______________________________________________________________________________________

Notes: ______________________________________________________________________________________


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