Get Physician Request Form For Patient Self-administered ...

Filling out the Physician Request Form for Patient Self-Administered Injectable and Specialty Drugs is a key step in ensuring a smooth processing of medication requests. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the Physician Request Form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Begin by entering the patient’s name, plan ID number, address, phone number, height, weight, and zip code. Ensure that all data is accurate.
3. Record the patient’s birth date and physician’s name. Include the physician’s NPI number, address, and contact details, such as phone number and email.
4. Indicate whether the member is currently residing in a Long-Term Care (LTC) facility by selecting ‘Yes’ or ‘No.’
5. Complete the section for the drug administration timeframe. Specify the dates or the particular date that the drug needs to be administered.
6. Provide the drug name and item number. Refer to the list of medications provided in the document to ensure it is included.
7. Fill in the ‘Sig (How Administered)’ field with details on how the medication should be administered.
8. Enter the diagnosis and the corresponding ICD-9 diagnosis code.
9. Provide justification for drug use in the space provided. If necessary, attach additional documentation.
10. Select the delivery method for the medication by choosing from the options: patient’s home, physician’s office, or local pharmacy.
11. The physician must sign the form and date it to validate the request.
12. Once the form is completed, save your changes, and download, print, or share the document as required.

Complete your forms online today to ensure timely processing of your requests.