Get Statement Of Medical Necessity (smn) - Genentech Access Solutions

Filling out the Statement Of Medical Necessity (smn) for Genentech Access Solutions is an essential process for obtaining necessary medical treatments. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the online form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's information. Fill out the last name, first name, and necessary contact details including street address, home phone, city, state, and ZIP code.
3. Indicate the insurance details. For each insurance type, provide the insurance name, phone number, subscriber name, subscriber ID number, and policy/group number. Ensure accuracy to avoid processing delays.
4. In the diagnosis/treatment section, check the appropriate boxes for the affected eye(s) and specify the relevant ICD-9-CM code(s). Indicate whether the patient has started treatment and, if not, provide the anticipated date.
5. Complete the prescription section clearly. Specify the vials requested, dosage, and instructions for use. Remember to indicate the preferred specialty pharmacy if needed and fill out the shipping address if different from the prescriber’s address.
6. Fill out the prescriber’s information, including name, practice name, contact numbers, and any required registration numbers. Ensure to leave space for the prescriber’s signature and date, as this is mandatory for processing.
7. Attach any necessary documents, such as the Patient Authorization and Notice of Release of Information (PAN) form, and a copy of the patient’s drug card if they have insurance. Check all information for accuracy before submission.
8. Review the completed form for legibility and completeness, then save changes and prepare the document for submission. You can download, print, or share the form as needed.

Complete your Statement Of Medical Necessity (smn) online to ensure timely access to necessary treatments.