Get Direct Ship Injectables Form
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How to fill out the Direct Ship Injectables Form online
The Direct Ship Injectables Form is designed to streamline the ordering of non-infusion injectable drugs for Keystone Health Plan East and Personal Choice® members. This guide provides step-by-step instructions on how to complete the form accurately and efficiently online.
Follow the steps to complete the Direct Ship Injectables Form.
- Press the ‘Get Form’ button to acquire the Direct Ship Injectables Form and open it in your editor.
- Begin by entering the date medication is needed at the top of the form. This ensures timely processing of your request.
- Fill in the patient information section by providing the patient’s full name, ID number, address, city, state, ZIP code, telephone number, date of birth, height, and weight. Make sure all details are printed clearly.
- Indicate delivery preferences in the specified section. Select ‘N/A’ if no delivery is required or check the box for delivery if that is needed. Specify the delivery location, either the physician’s office or the patient’s home.
- Complete the physician information section by entering the physician's name, NPI number, office contact, contact telephone number, address, city, state, ZIP code, office telephone number, and office fax number.
- In the prescribed drug/statement of medical necessity section, fill in the prescribed drug name, strength, sig, dispense quantity, refills (if applicable), diagnosis, and ICD-9 code. Include any comments or pertinent medical history that may assist in the authorization.
- Choose the prescription options by checking either ‘Substitution permissible’ or ‘Dispense as written’ based on the prescribing physician’s intent.
- Finally, the physician must sign the form. Note that a new form is not necessary for each refill; refills will be coordinated by the injectable distributor.
- Once all sections are complete, you can save changes, download the form, print it, or share it as needed.
Complete your Direct Ship Injectables Form online today to ensure timely and accurate medication delivery.
To complete a preauthorization, first fill out the Direct Ship Injectables Form accurately and completely. This form gathers essential information for the insurance company to process your request. After submitting, stay in touch with your provider to monitor the authorization status. Being proactive helps in addressing any potential delays or additional requirements from the insurer.
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