Get Va Premier Sublocade Injection Ciii Enrollment Form 2018-2025

Filling out the VA Premier Sublocade Injection CIII Enrollment Form online is an essential step for prescribers looking to ensure the proper administration of Sublocade for patients. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your enrollment form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the prescriber information section. This includes the prescriber’s name, address, phone number, fax number, DEA, and NPI.
3. Provide patient information. Enter the patient's name, address, date of birth, home phone number, and alternate phone number. Include the last four digits of the patient's Social Security number and language preference.
4. Complete the insurance information section. This necessitates filling out the insurance details entirely or attaching a copy of the patient’s insurance card.
5. In the medical information section, include the diagnosis with the corresponding ICD-10 code, any allergies, concomitant medications, weight, height, and BMI.
6. Move on to the prescription information. Fill in the medication name, dose/strength, directions, quantity, and refills. Be mindful that only one prescription can be written per blank.
7. Provide office contact and shipping information. Enter the contact person's name, phone number, shipping address, and the date the medication is needed.
8. Make sure to sign and date the form manually, as electronic signatures are not accepted.
9. Once all fields are completed, review the form for accuracy. Users can now save changes, download, print, or share the form as needed.

Take action now and complete your documents online for seamless processing.