Get Fidelis Hipaa Form

Filling out the Fidelis Hipaa Form online can streamline the process of submitting necessary medical information. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Fidelis Hipaa Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Begin by entering the patient information. Fill in the first name, last name, middle initial, member ID, and date of birth. Indicate the patient's gender and if they are transitioning from a facility. If applicable, provide the name of the facility.
3. Next, fill in the provider information. Include the provider's first name, last name, NPI number, phone number, address, fax number, office contact, and specialty.
4. Proceed to the medication, medical, and dispensing information section. Enter the medication name, strength, diagnosis or ICD-9 code, frequency, quantity, and refills. Specify the route of administration and indicate if the provider will be administering the medication.
5. Respond to the questions regarding the therapy's status among new medication uses, titration schedules, FDA indications, and any treatment failures with preferred drugs. Provide relevant therapeutic history and documentation if required.
6. Ensure to document any clinical information that supports the medical necessity of the request in the provided box. Attach any relevant lab results and check the box to confirm documentation is attached.
7. Complete the attestation section by confirming that the provided information is accurate and true. Ensure the prescriber’s signature and date are correctly filled out.
8. Once all sections are complete, you can save your changes, download the document, print it for further submission, or share it as required.

Take the next step in completing your documents online with confidence.