Get Pellets Service Request Enrollment Form

Completing the Pellets Service Request Enrollment Form online is a straightforward process that can facilitate your request for ® ( pellets). This guide provides clear, step-by-step instructions to help you navigate through each section of the form with ease.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Review the 'Program Services Requested' section. Here, you will select the appropriate options for either pre-treatment or post-treatment assistance regarding ®. Ensure to check the box for either 'Benefit/Coverage Investigation' or 'Prior Authorization Assistance' for pre-treatment, and select the relevant option for post-treatment needs.
3. Fill out the 'Patient Information' section. Provide the patient's full name, date of birth, address, phone numbers, and Social Security Number (SSN). Make sure all information is accurate to avoid any processing delays.
4. In the 'Insurance Information' section, attach copies of the patient's insurance cards (front and back). Complete details for the primary and secondary insurance, including subscriber information and policy identifiers.
5. In the 'Healthcare Provider Information' section, input the healthcare provider's name, specialty, practice name, and DEA number. Provide the provider's contact address and phone number as well.
6. Complete the 'Treatment Information' section by filling in the ICD-10 code and a description of the treatment. Indicate the anticipated treatment date.
7. Read the 'Authorization to Release Patient Information' section carefully. By signing this section, the user affirms that the therapy is medically necessary and that all patient information is authorized for release.
8. Finally, sign and date the form. Make sure the signature is entered by an authorized individual to validate the request.
9. Once all sections are completed, save any changes made to the form. You can then download, print, or share the filled form as needed to ensure submission to the appropriate parties.

Start filling out your Pellets Service Request Enrollment Form online today to facilitate your treatment process.