Get Coaguchek Physician Order Form

Filling out the Coaguchek Physician Order Form online is an essential process for facilitating patient self-testing for PT/INR. This comprehensive guide provides clear instructions on how to complete each section of the form effectively.

Follow the steps to complete the Coaguchek Physician Order Form online.

1. Press the ‘Get Form’ button to retrieve the Coaguchek Physician Order Form and open it in your preferred editor.
2. Complete the patient information section by entering the patient's first and last name, gender, home address, primary and secondary phone numbers, date of birth, and email address if available. Ensure all mandatory fields are filled out.
3. In the patient diagnosis code section, input all applicable diagnosis codes from the provided list. This is crucial as inaccurate entries could lead to processing delays.
4. Fill in the medical information section by specifying the therapeutic and notification ranges for INR testing. Indicate whether the patient has been on therapy for more than three months by selecting yes or no.
5. Indicate the contact person for receiving patient results, including their title, phone number, fax number, and email address. Choose the preferred method for receiving test results.
6. Select the prescribed frequency for INR tests, noting that Medicare covers up to one home INR test per week.
7. In the patient training section, select the training option that applies, confirming that face-to-face training has been completed.
8. In the physician authorization section, ensure that the prescribing physician signs and dates the form, and fills in their printed name and contact information.
9. Complete the insurance information section. Provide details of the primary and secondary health insurance companies, policy IDs, and customer service phone numbers if applicable.
10. Finally, review all sections for accuracy, ensuring that all required fields are completed. Save the changes, download, print, or share the completed form as necessary.

Complete your documents online for seamless processing.