Get Trokendi Xr Service Request Form - Needymeds

Filling out the Trokendi XR Service Request Form is a straightforward process that ensures necessary information is collected for assistance with the medication. This guide offers a step-by-step approach to completing the form accurately and efficiently, empowering users to navigate the online submission with confidence.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the Trokendi XR Service Request Form and open it for filling out.
2. Begin by providing the patient information in Step 1, which includes the patient’s name, date of birth, address, and phone numbers. If applicable, include the details for a parent or legal guardian.
3. In Step 2, review and sign the patient authorization section. This section requires the prescriber’s name, specialty, address, and contact information. Ensure that the prescriber’s contact details are accurate.
4. Proceed to Step 3 where you need to fill out the prescriber information. This includes the prescriber’s name, specialty, address, and contact numbers, including fax and NPI number.
5. In Step 4, complete the RX information by providing the diagnosis and ICD-9 code. List any anticonvulsant medications that have been tried previously along with the reasons for discontinuation, and indicate any medications the patient is currently taking.
6. For the prescription details, specify the strength, quantity prescribed, and directions for use of Trokendi XR. The prescriber needs to sign and date this section.
7. Finally, complete Step 5 by signing the prescriber authorization. Ensure the signature is clear and include the relationship to the patient before finalizing the form.
8. Once all sections are filled out completely and accurately, review the form. You can then save changes, download, print, or share the completed form to submit it online efficiently.

Start filling out your Trokendi XR Service Request Form online today for seamless assistance with your medication.