Get Client Profile Fillable Form

This guide provides step-by-step instructions for completing the Client Profile Fillable Form online. It is designed to assist users of all experience levels in accurately filling out the necessary fields.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the 'Date' field with the current date to ensure your submission is timely.
3. Input the 'Patient Name' and 'Patient Date of Birth' in the respective fields to identify the individual requiring authorization.
4. Enter the 'Provider DEA' and 'Provider Name' along with their 'Phone' number to specify the medical professional responsible for the request.
5. If known, provide the 'Pharmacy Name' and other relevant pharmacy details.
6. Fill in the 'Patient ID#' or 'Provider NPI' to link the form to the correct patient or provider.
7. Include the 'Fax' and 'Rx Phone' for communication purposes.
8. Specify the 'Drug Name/Strength' and include the dosage instructions in the designated area.
9. Indicate the 'Qty/Days Supply' for the medication being requested.
10. Attach copies of any supporting documentation to validate the medical necessity, answering the question on why the medication is necessary for the member.
11. If applicable, document any other medications that have been tried and include the details of the member's medical diagnosis.
12. Record any pertinent lab data that may support this request.
13. After completing the form, review all entries for accuracy before saving your changes, downloading, printing, or sharing the form as needed.

Complete your documents online for a smooth processing experience.