Get 855 239 9869

This guide will assist you in completing the 855 239 9869 form efficiently and accurately. Each step is outlined to ensure that you provide all necessary information properly.

Follow the steps to successfully complete your form.

1. Press the ‘Get Form’ button to access the document and open it in your preferred online editor.
2. Begin with the patient information section. Enter the patient’s name, date of birth, gender, address, city, state, zip code, email, home phone, and cell phone. If the patient does not have insurance, select that option.
3. If the patient has insurance, provide the details in the insurance information section. Fill in the primary insurance name, insurance phone number, policy ID, group number, policy holder's name, and the relationship to the patient. Include the work phone number and the best time to contact.
4. Include the pharmacy plan and the preferred specialty pharmacy information, if applicable. If there is a patient representative, enter their contact number as well.
5. In the medical profile section, list any drug allergies, concurrent medications, previously tried therapies, culture results, medication needed by date, height and weight, and expected discharge date.
6. For the prescription information, check the appropriate option for , and enter the quantity for each medication and its administration schedule.
7. Provide the patient case manager or prescriber contact information, including the preferred method of communication. Ensure all contact fields are filled accurately.
8. Complete the prescriber information section with the prescriber's name, specialty, hospital name, collaborating physician, and their contact details. Include the state license number and NPI number.
9. The prescriber must sign and date the form to certify that the therapy with oral is necessary and approve the release of medical information.
10. After filling out all required fields, review the document for accuracy, and then save your changes. You will have the option to download, print, or share the completed form.

Complete your documents online to ensure a smooth submission process.