Get () - Capital Blue Cross

This guide provides clear instructions for completing the ® () statement of medical necessity form. Following the steps outlined here will help ensure that all necessary information is accurately captured for processing.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the ® () statement of medical necessity form and open it in your preferred document editor.
2. Begin filling out the patient information section. Include the patient's name, sex, allergies, weight, height, date of birth, social security number, address, city, state, zip code, home phone, work phone, cell phone, email, and caregiver information.
3. Next, move to the prescriber information section. Fill in the prescriber's name, medical license number, NPI number, clinic name, specialty, contact name, address, city, state, zip code, phone, fax, and email.
4. Proceed to the insurance information section. Provide primary insurance details including policy number, group number, policy holder’s name, employer, and insurance phone number. Remember to include copies of the insurance cards to expedite processing.
5. Complete the clinical information section. Document the patient’s gestational age, birth weight, current weight, and date recorded. Ensure that you provide detailed diagnoses using ICD-10 codes.
6. For the medical criteria, check all applicable conditions and fill out relevant information regarding the patient's medical history, NICU history, and oxygen use.
7. In the prescription section, specify the medication details, dosage instructions, and any additional notes necessary for medication dispensation.
8. Collect the necessary signatures. Ensure the patient and prescriber sign and date the form where indicated.
9. Finally, save changes to the document, and then download, print, or share the completed ® () statement of medical necessity as needed.

Complete your forms online efficiently and accurately for faster processing.