Get Caresite Specialty Rx Referral Ms Revised.doc

Filling out the CareSite Specialty Rx Referral MS Revised.doc online is an important step in facilitating care for individuals with multiple sclerosis. This guide will provide you with clear, step-by-step instructions to successfully complete the form, ensuring all necessary information is accurately provided.

Follow the steps to complete your CareSite Specialty Rx Referral form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the patient information. Fill in the patient's name (last, first, middle initial), date of birth, gender, and social security number. Make sure to provide the street address, city, state, and zip code.
3. Indicate the patient’s co-pay method by selecting either 'Credit Card' or 'Check by Mail'. If applicable, fill in the card type and card number, including the expiration date.
4. Provide any known allergies of the patient, as well as the daytime and evening phone numbers.
5. Complete the insurance information section by attaching a copy of the patient's insurance card (front and back). Include the primary insurance name, policy holder's name, policy number, group number, and phone number.
6. In the diagnosis section, select the primary diagnosis of 'Multiple Sclerosis' or specify another ICD9 code. Indicate whether the patient is new to therapy by selecting 'yes' or 'no' and include the date of diagnosis.
7. List previous medications taken by the patient. Specify the medication name, strength, dosage, duration on therapy, and the reason for discontinuing each medication.
8. For prescription information, fill in the required fields for each medication prescribed, including Rx-medication, dose and frequency, and quantity. Ensure that specific medications that require dosage titration are accurately detailed.
9. In the delivery and patient education instructions section, indicate whether transportation will be to the patient’s home or physician's office. Specify if the patient requires an education kit and note the date needed.
10. Lastly, complete the physician contact information by filling in the physician’s name, license number, DEA number, office contact, fax, and address. The physician should also sign and date the form.
11. After completing all sections, review the form for accuracy. You have the option to save changes, download, print, or share the form as needed.

Complete your CareSite Specialty Rx Referral MS Revised.doc online today to ensure timely care.