Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the document and open it in the editor.
2. Begin by filling out the member information section. Provide your first name, last name, plan name, member ID, and date of birth.
3. In the requested drug information section, specify the drug name, select the appropriate choice for new start, change in current therapy/dosage, or continuation of current therapy. Also, indicate the quantity needed.
4. Fill in the necessary medical information such as ICD-9 code, directions for use, and duration of therapy.
5. Document the diagnosis and list any alternative therapies that have been attempted. Include any relevant information related to the drug and the disease state.
6. Complete the metrics section by inputting the relevant health metrics like ESR, CRP, height, weight, and other provided fields.
7. In the physician information part, ensure the physician signs and dates the form. Fill in the physician's name, NPI number, and contact details.
8. Select the action needed, marking 'Urgent' only if necessary. Lastly, provide the pharmacy fax number if applicable.
9. Once all sections are filled out, review the form carefully for any errors or missing information.
10. Save your changes, and prepare to download, print, or share the completed form as needed.

Complete your documents online today to ensure timely processing!