Get Prescription Referral Form -

Filling out the prescription referral form online is a vital step in ensuring patients receive the necessary treatments for their conditions. This guide provides clear, step-by-step instructions to help users accurately complete each section of the form with confidence.

Follow the steps to complete the prescription referral form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, provide the patient's information. Fill in the name, date of birth, address, caregiver contact, city, state, ZIP, sex, home phone, cell number, weight, height, email, diagnosis code (ICD-10), and current therapy for immunoglobulin treatments.
3. In Section B, indicate the patient's insurance information. Record details for primary and secondary insurance providers, participating status of the prescriber, policyholder’s name, employer information, and include fax copies of insurance cards as instructed.
4. In Section C, detail the initial treatment setting and patient training preferences. Indicate if the Specialty Pharmacy should provide training and if they should contact the prescriber regarding patient progress.
5. In Section D, include the prescription order for . Complete the dosing schedule, total dose, subcutaneous sites, ancillary supplies required, and any special instructions regarding allergies or additional medication.
6. Ensure both prescriber signatures are obtained at the bottom of the form to authorize the prescription and confirm the medical necessity for the treatment. Check that the completed form maintains clarity and correctness throughout.
7. Once all sections are thoroughly filled, save your changes. You may then download, print, or share the completed form via email as needed, ensuring secure transmission of sensitive patient data.

Start filling out your prescription referral form online today to ensure timely access to treatments.