Get Chemotherapy Data Collection Form

This guide provides clear instructions for users on how to fill out the Chemotherapy Data Collection Form online. Completing this form accurately is crucial for the review of chemotherapy services and can help ensure a seamless process.

Follow the steps to complete the Chemotherapy Data Collection Form online.

1. Press the ‘Get Form’ button to access the Chemotherapy Data Collection Form. This action will open the form in your digital workspace.
2. Fill out the Contact Information section. Provide your name, phone number, fax number, and an alternate phone number if necessary. Indicate whether you should be contacted for any questions, and if not, note the alternate contact's name and number.
3. Next, proceed to the Physician Information section. Here, input the oncologist's name, address, tax identification number (TIN), and both their primary and alternate phone numbers. Also, include their fax number.
4. In the Patient Information section, enter the patient's name, address, subscriber ID, group number, date of birth, and phone number. Ensure this information is accurate as it relates to the patient's treatment.
5. Complete the Proposed Treatment Regimen section by indicating the line of therapy for treatment and listing all chemotherapy agents to be used. For drugs without assigned J codes, use unlisted J code, J3490, and include the drug name.
6. Fill out the Required Information Related to Request section. Provide the anticipated therapy start date, primary ICD code, secondary ICD code, and any additional ICD codes. Answer the questions regarding the patient’s medical history.
7. If applicable, detail the Treatment History for Metastatic/Relapsed Disease section. Check if the member has not received previous treatment and list drugs from first and second line therapies, including their HCPC codes.
8. Add any additional comments in the designated section towards the end of the form. This allows for any important information that may not be covered in the previous sections.
9. Review all entered information for accuracy. Once confirmed, users can save changes, download, print, or share the completed form as necessary.

Complete your Chemotherapy Data Collection Form online now to ensure efficient processing of your request.