Get Pa Infucare Rx Rheumatology Iv Infusion Referral Form 2020-2025

Completing the PA InfuCare Rx Rheumatology IV Infusion Referral Form online can help streamline the referral process for rheumatology IV infusion services. This guide provides you with comprehensive, step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to complete the referral form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your digital editor.
2. Begin with the 'Patient Information' section. Fill in the patient's name and ensure to provide the required shipping address. Include the date required and the MD office contact details.
3. Next, complete the 'Prescriber Information' section. Input the prescriber's name, their office address (including city, state, and zip code), and various phone numbers, ensuring to include the DEA and NPI numbers.
4. Proceed to the 'Insurance Information' section. Attach the front and back of the insurance and prescription drug card, and fill in details for both the primary and secondary insurance, including IDs and group numbers if applicable.
5. In the 'Patient Diagnosis/Clinical Information' section, select the appropriate diagnosis codes. Record any TB/PPD test results, weight, height, allergies, and notes on home health nursing coordination.
6. Continue to the 'Prescription Information' section. Fill in the medication prescribed, including dose/strength, administration directions, and quantity. Be sure to indicate if there are any pre-medications or additional protocols required.
7. Complete the form by signing and dating it in the designated area to authorize InfuCare Rx to act as a prior authorization designated agent. Ensure all information is correct before submission.
8. Finally, save your changes and choose the option to download, print, or share the completed form as needed.

Complete and submit your documents online today to ensure a smooth referral process.