Get Replacement Form

This guide provides a comprehensive overview of the steps required to complete the Replacement Form online. It is designed to assist users at all levels of experience in navigating the form effectively.

Follow the steps to complete the Replacement Form successfully:

1. Press the ‘Get Form’ button to access the Replacement Form. This action will allow you to obtain the form and open it for editing.
2. Begin by entering the facility name and customer number. These fields are essential for identifying the requesting party and should be accurately completed.
3. Next, provide the shipping address details, including Shipping Address 1, Shipping Address 2 (if needed), city, state, and zip code. Ensure that all information is entered clearly to avoid any shipping issues.
4. Fill out the facility contact information. Include first name, last name, title, and contact phone and fax numbers. This data will allow for prompt communication regarding your request.
5. Input patient details: last name, first name, and date of birth (in MM/DD/YYYY format). Accurate patient information is vital for processing the request.
6. Specify the product name, unit of measure (UOM), strength, and quantity of vials, syringes, or units dispensed. These details are critical for ensuring the correct product is requested.
7. Indicate the administration start and end date, along with the total number of administrations—required for specific products like ®, ®, or ®.
8. Complete the prescriber section by entering the ® provider name and necessary identification numbers. This information is important for validation purposes.
9. Review the certification statement and confirm your agreement by providing either the physician or facility contact signature. Remember that a physician's signature is required for exact quantities.
10. Finally, enter the date, the physician's state license number, and their email address for communication. Once completed, assess the form for any errors before submission.
11. Fax the completed form to 1-877-727-2867 and ensure you keep a copy for your records. Users can also save changes, download, and print the document as necessary.

Take action today and complete your Replacement Form online to facilitate a smooth request process.