Preauthorization Request Form

A Hyperhidrosis Preauthorization Request Form may be copied or printed from below and used to notify an insurance organization that a patient has been diagnosed with hyperhidrosis, and to demonstrate the degree to which his or her life is negatively affected by excessive sweating. There is also space on the form for you to note hyperhidrosis treatments that the patient already tried and the next treatment that you are recommending. The form should be completed and submitted to the appropriate health insurance organization by the treating clinician.

ICD-10 Codes:

L74.510 - Primary focal hyperhidrosis, axilla
L74.511 - Primary focal hyperhidrosis, face
L74.512 - Primary focal hyperhidrosis, palms
L74.513 - Primary focal hyperhidrosis, soles
L74.519 - Primary focal hyperhidrosis, unspecified
L74.5 Focal hyperhidrosis
L74.51 Primary focal hyperhidrosis
L74.52 - Secondary Focal Hyperhidrosis
L74.8 Other eccrine sweat disorders
L74.9 Eccrine sweat disorder, unspecified
R61 - Generalized Hyperhidrosis R61

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 & sometimes interferes with daily activities

__Sweating is barely tolerable & frequently interferes with daily activities

__Sweating is intolerable & 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

__ Topical anticholinergic (Qbrexza™)

__BOTOX®

__miraDry®

__Oral Medications

__Psychiatric medications/care

__Surgery (Local)

__Surgery (ETS)

__None

Recommended Treatment for: