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Get Silverscript 5246-24762a 2012-2025
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How to fill out the SilverScript 5246-24762a online
Filling out the SilverScript 5246-24762a form online is a crucial step toward obtaining necessary prescription drug coverage. This guide provides a step-by-step approach to ensure that you complete the form accurately and efficiently.
Follow the steps to successfully complete the SilverScript 5246-24762a form.
- Press the ‘Get Form’ button to access the SilverScript 5246-24762a form and open it in your online editor.
- Begin by entering the patient's personal information, including their name, member ID, Medicare ID, date of birth, sex, address, city, state, ZIP code, and phone number. Additionally, indicate whether the patient is a nursing home resident or a home care patient.
- Next, provide the details for the prescriber and pharmacy. Enter the prescriber's name, specialty, DEA number, NPI number, address, city, state, ZIP code, phone number, and fax number. Also, fill in the pharmacy name, NCPDP number, NPI number, phone number, and fax number.
- Complete the section related to the requested drug by filling in the drug name, selecting whether the drug is brand or generic, noting the strength, dosage form, and quantity prescribed for 30 days. Specify if this is a new prescription or a refill and include the directions for usage, diagnosis, and ICD-9 code.
- If you need an expedited review, indicate your request at the top of the form. Ensure that you provide medical justification for the non-formulary drug request, addressing why alternative formulary drugs would not be effective or would cause adverse effects. Document any previous drugs attempted and their outcomes.
- Complete any additional fields as required for medical justification, including signing and dating the form to attest that the information provided is accurate.
- Review all completed sections for accuracy. Once verified, you can save changes, download a copy, print it, or share the form as needed. Finally, fax the completed form to 855-633-7673.
Take action now by filling out the SilverScript 5246-24762a form online to ensure timely processing of your prescription drug coverage requests.
Filling out a prescription form begins with entering the patient’s name, the date, and the details of the medication prescribed. Ensure that you write the dosage and any instructions clearly, then sign the form. Utilizing SilverScript 5246-24762a can provide you with templates and tools that help simplify this process.
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