Get Home Infusion Request Form - Gateway Health Plan

Completing the Home Infusion Request Form for Gateway Health Plan is a straightforward process that ensures necessary information is accurately conveyed. This guide aims to help users navigate the form effectively and provide step-by-step instructions to facilitate the online filling process.

Follow the steps to complete your Home Infusion Request Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin by filling out the patient’s name in the designated field to ensure accurate identification.
3. Enter the member ID, which is essential for verifying eligibility for services.
4. Provide the date of birth (DOB) for the patient to confirm age-related criteria.
5. Fill in the pharmacy name where the requisition will be processed, ensuring it is a pharmacy in network.
6. Designate a contact person at the pharmacy along with their phone number for efficient communication.
7. Specify the drug required for home infusion, ensuring to include the National Drug Code (NDC) for accuracy.
8. Enter the appropriate diagnosis code (DX Code) to justify the medical necessity of the infusion.
9. Indicate the dose and frequency of the drug to provide clear guidelines for administration.
10. List the nursing requirements along with the quantity needed for administering the infusion.
11. Include the supply code(s) and the quantity necessary to support the home infusion therapy.
12. Specify the administration type (pump, gravity, injection, etc.) to ensure proper delivery method is followed.
13. Provide the prescriber’s full name and their contact details, including phone number and fax number, for verification and follow-up.
14. Fill in the start and end dates for the infusion therapy to establish a treatment timeframe.
15. Make sure to include all orders for medications that are not listed on the covered home infusion list, as this is crucial for approval.
16. Review all entries for accuracy before you finalize the form.
17. Save changes to the document, then choose to download, print, or share the completed form as necessary.

Complete your Home Infusion Request Form online and ensure timely processing for your home infusion needs.