Preauthorization Request Form

This Hyperhidrosis Preauthorization Request Form may be downloaded (or printed from below) 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 healthcare provider 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 provider. You can help your practitioner by printing the form and taking it to your next appointment.

ICD-10 Codes:

L74.5 Focal hyperhidrosis

L74.51 Primary focal hyperhidrosis

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

L74.52 Secondary focal hyperhidrosis

L74.8 Other eccrine sweat disorders

L74.9 Eccrine sweat disorder, unspecified

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: