Get Injectable Drug Request Form

Filling out the Injectable Drug REQUEST FORM online can streamline the process of obtaining necessary medications. This guide offers a step-by-step approach to ensure that users provide accurate and complete information.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the physician information section. Provide the first, middle, and last name of the physician along with the street address, including any apartment number, city, state, and zip code. Include their date of birth, member ID number, and group number if applicable.
3. Indicate who is responsible for payment by providing the necessary contact information. Ensure to include a phone number and work number, along with a printed name.
4. Next, complete the statement of medical justification. Include pertinent test results and reports as required. Specify the prescribed drug, date needed, dose, quantity per month, and duration of use. Also, include the ICD9/Dx code and indicate if this is for chemotherapy use by selecting ‘YES’ or ‘NO’.
5. The physician must provide their signature to validate the request.
6. In the shipping information section, specify the destination for the medication. Choose whether to send it to the physician's office or another address, and fill in the corresponding details accordingly.
7. After completing all fields, review the information for accuracy, and ensure that a copy of the patient’s ID card is included as part of the submission.
8. Finally, save the changes, and download, print, or share the form as needed.

Start completing your documents online now for a hassle-free experience.