CSS Synagis Referral Form

Your patient must have a CCS eligible medical condition AND be 24 months or younger at start of RSV season for CCS to authorize Synagis. Prematurity, in and of itself, is not a CCS eligible condition. Infants born prematurely needing Synagis who do not have a CCS eligible condition should be referred to either Medi-Cal or the appropriate Healthy Families insurance plan.
Please fill in all fields marked with a *
Today's Date *
Referred By *
Your Phone Number *
Your Fax Number
Patient Information
Patient Name *
Parent or Caretaker Name *
CCS Number *
Other Insurance
Policy Number *
Insurance Phone Number *
Patient Address *
City/State/Zip *
Patient Phone Number *
Mother's SSN *
Mother's DOB *
Condition and Environment Information
CCS Eligible Medical Condition *
Other Conditions
Choose Appropriate Gestational Age *
Other Factors
CCS Paneled Physician Administering Synagis *
Synagis Prescription Information
Current Weight *
Date of Current Weight *
Give Q 25 30 Days for how many months *
Requesting CCS Paneled Physician *
Physician Address *
Physician Phone Number *
Physician DEA Number *
CA Lic Number *
CCA Paneled Specialist *
Date *