Get Alpha 1 Form-prolastin, Aralast, Zemaira, Glassia- Excellus Final 093010.doc

Filling out the Alpha 1 Form for Prolastin, Aralast, Zemaira, and Glassia is a crucial process for individuals seeking specialty medication coverage. This guide aims to provide clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in your browser.
2. Begin by entering the patient information. Fill in the 'Patient Name,' 'Patient Phone Number,' and 'Patient ID Number' accurately. It is essential to print the name clearly for proper identification.
3. Indicate any patient allergies in the designated field. If there are none, you may leave this blank.
4. Provide the prescribing physician's information including 'MD Name,' 'MD NPI Number,' and 'MD DEA Number.' This information ensures that the prescribing physician is properly recognized.
5. Fill in the 'Patient Birthdate' and 'MD Specialty' fields. Ensure that the details match official documentation.
6. In the 'Location of Infusion' section, select the appropriate option (e.g., MD office, outpatient facility, home, or other) by marking the checkbox.
7. Complete the 'Medication Shipping Address' section with the necessary details to ensure proper delivery.
8. Address the questions regarding medical necessity. Carefully check the boxes that apply to the patient's situation regarding the required medication.
9. After confirming that all information is correct and complete, review the certification statement. Ensure that the prescriber’s information and signature are included, along with the date.
10. Once you have filled out the form, save your changes, download the document, and prepare for faxing to the appropriate numbers listed on the form.

Start filling out your forms online today for a seamless submission experience.