Get Accredo Form

The Accredo Form is essential for requesting respiratory syncytial virus (RSV) prophylaxis. Completing this form accurately ensures that patients receive the necessary treatment. This guide provides clear, step-by-step instructions for filling out the form online.

Follow the steps to complete the Accredo Form online

1. Click ‘Get Form’ button to open the Accredo Form in your online editor.
2. Begin by filling out the patient information section. Include the patient's name, date of birth, and address. Record the patient’s gestational age, current weight, and birth weight. Ensure all fields are completely filled.
3. In the primary diagnosis section, select the applicable gestational age category based on the patient's condition. This is critical for determining the medical necessity of RSV prophylaxis.
4. Provide details about the patient's medical history and any secondary diagnoses. This may include chronic respiratory diseases and congenital heart conditions. Be sure to check all relevant boxes and provide dates of treatment received.
5. Fill in the insurance information section. Include details for both primary and secondary insurance, ensuring accuracy to facilitate coverage. Attach copies of the patient's insurance cards.
6. Complete the physician information section. Enter the prescriber's name, hospital or clinic information, and contact details. Ensure all required identifiers, like DEA and license numbers, are included.
7. Answer the questions regarding NICU history and expected dates for the RSV treatment. Check the boxes for injected products and provide prescriptions as necessary.
8. Review all the information entered to ensure accuracy before finalizing. Make sure that the prescriber’s signature is included as required.
9. Once completed, you can save the changes, download, print, or share the form as needed. Ensure that the form is faxed to the specified number, 866.297.0934, for processing.

Complete the Accredo Form online today to ensure timely and effective treatment.