Get Immunoglobulin Physician Referral Form

Filling out the Immunoglobulin Physician Referral Form online can streamline the process of referring patients for immunoglobulin therapy. This guide provides step-by-step instructions to ensure that all required information is accurately submitted.

Follow the steps to complete the Immunoglobulin Physician Referral Form online.

1. Click the ‘Get Form’ button to access the Immunoglobulin Physician Referral Form online and open it for editing.
2. Start by filling in the patient's basic information: include the date, name, date of birth (DOB), address, city, state, zip code, and phone number.
3. Next, provide the patient's social security number and sex by selecting M for male or F for female.
4. In the insurance section, enter the primary insurance information, include the subscriber's name, DOB, ID number, and policy or group number. If a secondary insurance applies, complete that section as well.
5. Indicate whether the physician would like to be contacted with insurance information prior to the patient being contacted.
6. Fill in the physician's details including their name, phone number, address, DEA number, office contact, and fax number.
7. In the diagnosis section, include necessary medical history and relevant ICD-9 codes for the patient's conditions.
8. Complete the therapy section by specifying the immunoglobulin product, dosage, route of administration (IV or SC), frequency, and any additional orders or information regarding administration.
9. If applicable, indicate if the patient has previously received immunoglobulin therapy and whether they can self-infuse.
10. Finalize by certifying that the prescribed therapy is medically necessary, ensuring all information is correct, and signing with the date.
11. Save changes, download the completed form, and print or share it as required.

Start filling out the Immunoglobulin Physician Referral Form online today for efficient patient referrals!