Get Wellcare Injectable Infusion Form

This guide will provide you with clear, step-by-step instructions on how to properly complete the Wellcare Injectable Infusion Form online. Following these steps will ensure that your submission is accurate and complete.

Follow the steps to fill out the Wellcare Injectable Infusion Form carefully.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Identify who is making the request by selecting the appropriate option: provider, member, or appointed representative. If you are an appointed representative, ensure you include a signed Appointment of Representative form (CMS-1696) or an equivalent notice.
3. Choose between requesting a standard review or an expedited review. Check the box associated with your choice. Remember, not checking a box defaults to a standard review.
4. Fill out the member's information completely. This includes the member's name, member ID, address, city, state, zip, phone number, height, weight, allergies, and current medication.
5. Provide the member's date of birth, diagnosis, ICD-9 code, dosage, and any relevant provider details such as name, address, phone, fax, contact name, and provider ID/NPI.
6. Specify the frequency of the medication and the date of request as well as the expected length of treatment. If additional lines are needed, use another form.
7. The physician must sign the document, and you should provide clinical rationale for any override or exception requests. List names and doses of previous medications tried and failed.
8. Answer the questions regarding the member's living situation: long-term care facility, physician's office administration, facility/outpatient clinic, or at-home administration. Fill in any required details where necessary.
9. After filling out the form, review all information for accuracy and completeness. Ensure any required supporting documentation is attached.
10. Save changes, and then download, print, or share the completed form as needed. FAX the form to 1-866-388-1767 WellCare Pharmacy Department.

Start your document filing process by completing the Wellcare Injectable Infusion Form online today.