Get Renewal Form

Completing the Renewal Form online is a straightforward process designed to help you manage your health care needs efficiently. This guide provides clear, step-by-step instructions to ensure that your information is submitted accurately and securely.

Follow the steps to complete your Renewal Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. This includes the first name, middle initial, last name, gender, and social security number of the patient.
3. In the prescriber and prescription information section, enter the prescriber’s first name, last name, date of birth, email address, primary language, DEA number, middle initial, degree, NPI number, tax ID number, and state license number.
4. If your contact information has changed, complete the corresponding section with your current phone number, alternate phone number, best time to call, address, facility name, affiliated hospital, specialty, office contact name and phone, office email address, city, last name, state, ZIP code, phone number, and primary address.
5. Indicate your preferred method of contact by selecting phone or fax. If applicable, provide the details for the legal guardian or emergency contact.
6. Answer the questions for renewal patients regarding liver function tests and pregnancy status. This includes confirming if the patient is female of childbearing potential and if a negative pregnancy test has been confirmed.
7. Before submitting, ensure that all sections of the form are complete and accurate. Finally, you or the prescriber must sign and date the form to certify that all information is truthful and that counseling on risks has been provided.
8. Once all information has been entered and verified, you can save changes, download, print, or share the completed form as necessary.

Complete your Renewal Form online to ensure continued access to necessary care.