Submitting a Statement of Medical Necessity SMN for Humatrope somatropin rDNA origin for injection INFORMATION NEEDED FOR FULL SMN FORM SUBMISSION PATIENT INFORMATION Please provide Patient Name and Date of Birth INSURANCE INFORMATION Please attach a complete copy of the patient s insurance card both front and back sides PRESCRIPTION OPTIONS Select Vial or Pen Specify dose dose frequency and number of refills PR
PV 7981 CAP PI CES DU STYLO HUMATROPEN 6 MG PI CES DE L AIGUILLE AIGUILLES NON FOURNIES Humatrope somatotrophine Cartouche d Humatrope de 6 mg Bouton vendue s par ment Corpsdu d injection H U MAT RO D E N G m g Tige stylo de 6 mg Capuchon Languette Di tif d iniecti de l h j aame Er interne de papier ispositi injection de l hormone P En od R de croissance Ja Do em re a L Dispositif d injection utiliser MANUEL D UTILI
PV 7971 CAP HUMATROPEN 6 MG PARTS PEN NEEDLE PARTS PEN NEEDLES NOT INCLUDED Humatrope somatropin Humatrope Injection 6 mg Cartridge Button sold separately 6 mg Screw Pen Body Inner Cap Paper Tab HUMATROPEN 6 mg ean a Growth Hormone Delivery System 1 M a e P an Injection Device for Use with PEN USER MANUAL mg Humatrope somatropin Cartridges Outer Cap Naadle Pen Rubber Front Dose Cap Seal Housing Window a Whit