Get Request For For Respiratory Syncytial Virus (rsv)

This guide provides clear and supportive instructions for completing the REQUEST FOR FOR RESPIRATORY SYNCYTIAL VIRUS (RSV) form online. By following these steps, you will ensure that all necessary information is accurately provided for the request.

Follow the steps to effectively complete your RSV request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's information in the designated fields. This includes the patient's last name, first name, middle initial, address, city, state, date of birth, and telephone numbers.
3. Next, fill in the member ID number and sex of the patient, as well as the name of the parent or guardian.
4. Proceed to the physician information section. Input the prescriber's last name, first name, office contact, state, and telephone number. Also, include the Provider ID number, NPI number, and the name of the primary care physician.
5. Document the patient's gestational age, birth weight, current weight, and the date these details were recorded.
6. Complete the medical criteria section by indicating whether the patient meets the necessary diagnoses and providing relevant ICD-9 codes.
7. Check the boxes for any medical treatments the patient is currently receiving and provide the last date received.
8. In the statement of medical necessity section, specify the prescribed medication () dosage and additional instructions as necessary.
9. Indicate the expected date of the first or next injection and specify whether the product will be delivered to the office or home.
10. Finally, review all entries for accuracy, ensure that the prescriber's signature and date are completed, and confirm if the patient received previous injections this season.
11. Once all sections are filled out, save your changes, download, print, or share the form as needed.

Complete your request for the RSV online today to ensure timely and efficient processing.