Get Referral & Prescription Form

Filling out the Referral & Prescription Form online can streamline the process of obtaining necessary medical treatments. This guide will provide comprehensive, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Referral & Prescription Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. Fill in the patient's name, date of birth, gender, social security number, street address, weight, height, allergies, home phone, cell phone, city, state, zip code, and an alternate contact name and relationship.
3. Next, provide the insurance information. Attach a copy of the patient’s insurance card (front and back). Enter the primary and secondary insurance details, including their respective phone numbers, ID numbers, group numbers, BIN numbers, and PCN numbers.
4. In the diagnosis section, indicate the primary and secondary diagnoses, along with their ICD-9 codes.
5. Move on to the prescription information. Fill in the required fields for the medication name, dose, route, frequency, and the number of refills. Specify the dispense method (IV, IM, SQ, PO) for each medication listed.
6. Complete the instructions and notes section. Enter the therapy start date and indicate whether to contact the patient directly, if patient assistance should be initiated, if the office should be contacted first, and if injection training is required.
7. Finally, fill out the physician contact information and authorization. This includes the physician's name, license number, DEA number, office contact, fax number, street address, signature, phone number, NPI number, and the date. Ensure all necessary information is completed for the prescription to be filled generically unless otherwise noted.
8. After confirming that all sections of the form are completed accurately, save your changes. You can then download, print, or share the form as needed.

Take the next step towards your health by completing the Referral & Prescription Form online today.