Get Patches And Express Scripts Form

Filling out the Patches And Express Scripts Form online can streamline the prior authorization process for your prescription. This guide will provide clear and detailed instructions to help you complete the form accurately.

Follow the steps to successfully complete the form

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the patient's information. Fill in the first and last name, patient ID number, date of birth, and phone number in the respective fields.
3. Next, provide the prescriber's details. Include the prescriber’s name, DEA/NPI number, phone number, fax number, and address, ensuring the state and zip code are correct.
4. Indicate the primary diagnosis and corresponding ICD code. Familiarize yourself with the options such as low back pain, postherpetic neuralgia, and others listed.
5. Specify the directions for use for the patch, detailing the frequency and quantity.
6. Complete the clinical assessment. Answer the questions regarding previous medications tried for low back pain and osteoarthritis, providing any necessary details.
7. If there are additional comments, diagnoses, or symptoms, include that information in the final section.
8. Ensure the prescriber signs and dates the form. Include the office contact name and phone number for any follow-up.
9. Once all fields are filled out completely and accurately, you can save your changes, download the form, print it, or share it as needed.

Complete your documents online to expedite the prior authorization process.