Get Psoriasis Referral Form - Prime Therapeutics

Filling out the psoriasis referral form for Prime Therapeutics can be a straightforward process when guided step-by-step. This guide will help you understand each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to fill out the form online.

1. To obtain the form, click ‘Get Form’ button to download and open the document in your preferred PDF editor.
2. Start by filling out the patient information section. Here, you will need to provide the patient's first name, last name, date of birth, address, city, state, zip code, and any middle initial.
3. Next, complete the prescriber information. This includes entering the prescriber’s first name, last name, NPI number, office name and contact, address, city, state, zip code, phone number, DEA number, and fax number.
4. Ensure to fax a copy of the front and back of all insurance cards. In the primary insurance section, enter the insurance provider's name, policy ID number, group number, policyholder's name, and their date of birth.
5. Proceed to the clinical information. Fill in the primary diagnosis code (either ICD-9 or ICD-10), height, weight, other health conditions, other diagnosis, allergies, and current medications.
6. Indicate the date of diagnosis and the duration of the disease. You will also need to specify the percentage of body surface area (BSA) affected by psoriasis, severity of the condition, and the TB test result along with the date.
7. In the prescription information section, indicate the medication prescribed by checking the appropriate box for the chosen treatment. You can select from options such as , , , and more.
8. For the prescribed medication, determine whether it is a new prescription or a refill, and specify the form and strength of the medication required. Input the quantity, administration directions, and number of refills needed.
9. It is essential to sign the form as a prescriber. Verify that the signature is legibly written and check the box indicating whether to dispense as written or allow substitutions.
10. After completing the form, you can save your changes, download a copy for your records, and print the form if needed. Finally, ensure to fax the completed form to 877.828.3939.

Begin your journey by filling out the psoriasis referral form online today.