Get Service Request Enrollment Form - La

This guide provides a clear and structured approach to filling out the Service Request Enrollment Form - LA online. By following these instructions, users can ensure that they accurately complete the necessary fields to facilitate service requests efficiently.

Follow the steps to complete the form accurately and effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by completing the patient information section. Include the patient's full name, address, date of birth, sex, and insurance details. Be sure to attach a clear copy of the patient’s insurance card.
3. Next, fill out the healthcare provider information. This includes the provider's name, specialty, contact information, and any relevant license numbers.
4. In the treatment information section, indicate the specifics of the treatment related to ® LA. Fill in details like the surgeon’s office and any required test results, ensuring to document any ICD-9 codes as applicable.
5. Provide prescription information, ensuring that the prescriber’s signature is included. Confirm that all relevant details related to medication dispense and refills are accurate.
6. Coordinate the product delivery by specifying the preferred shipping information and the location for the procedure. If applicable, include the scheduled date for insertion.
7. Complete the certification of medical necessity and authorization to release patient information. This step is essential for ensuring compliance with privacy regulations.
8. Finally, review the entire form for accuracy. Save changes, and download or print the completed form for submission. Ensure all necessary documents are attached before faxing the form to the provided number.

Start filling out the Service Request Enrollment Form - LA online today to ensure timely service request processing.