Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the document and open it in your editing platform.
2. Fill in the 'Requested by' section by selecting one of the options: Physician, Member, Pharmacy, or Appointed Representative. Ensure you provide the correct identification for the requesting party.
3. Complete the 'Submitted' section by entering the Member ID, Provider ID, and the names and addresses for both the member and provider. Verify that all details are accurate and legible.
4. Input the phone number and date of birth of the member, and include their height, weight, and diagnosis (Dx). Note the weight should be indicated in either pounds (lb) or kilograms (Kg).
5. List any allergies and the relevant ICD-9 codes associated with the member's diagnosis.
6. Provide details about the medication, including its name, dosage, frequency, and length of treatment required.
7. Have the physician sign the form in the designated area. Include a clinical reason for the override, detailing medications that have been tried and the laboratory results, as needed. Additional explanations can be provided on supplementary pages.
8. Indicate whether the member resides in a long-term care facility and if the medication will be administered in the provider's office. Make sure to clarify who is responsible for collecting the co-payment.
9. Include the details of the address for medication delivery, whether it is being sent to the provider's office or another location. Ensure all delivery information is completely filled out.
10. Answer questions regarding where the medication will be administered—patient's home, facility, or outpatient center. If applicable, provide the facility name and provider ID.
11. If an expedited review is requested, certify that the standard review time frame could jeopardize the member's health. Ensure this section is signed appropriately.
12. After completing all sections, review the form carefully for any errors or omissions before finalizing.
13. Once verified, save your changes, and download the completed form. You can opt to print it out or share it via email as needed.

Start the process today by completing the Wellcare Injectable Infusion Form online.