Get Statement Of Medical Necessity Form. Use This Form To Enroll Patients In Access

Filling out the Statement Of Medical Necessity Form accurately is essential for enrolling patients in the Access program. This guide provides step-by-step instructions to assist healthcare professionals in completing the form effectively, ensuring timely processing and enrollment.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the Statement Of Medical Necessity Form and open it in your document editor.
2. Carefully fill in the services requested section by checking the appropriate services that apply for the patient. Ensure you check options like benefits investigation and prior authorization, as these are crucial for processing.
3. In the patient information section, complete all required fields with accurate details including the patient's name, birth date, contact information, and preferred language. Use legible handwriting to prevent processing delays.
4. Provide comprehensive insurance information by entering details of the patient’s primary and secondary insurance, if applicable. Ensure you attach legible copies of all insurance cards.
5. Fill out the prescriber information, including the prescriber’s name, practice name, contact details, and any relevant identifier numbers such as NPI and DEA. Correct information is vital for insurance review.
6. Complete the diagnosis and clinical information section. Ensure you check the correct codes for the patient’s condition and provide lab results and pretreatment serum IgE levels, if relevant.
7. Indicate the prescription information by selecting the appropriate prescription type and dosage. Provide details on quantity dispensed and refills as needed to avoid delays in fulfilling prescriptions.
8. Specify acquisition and administration details. Indicate if a specialty pharmacy is required and the anticipated date of treatment, as well as the place of administration.
9. If applicable, check the box to request a starter supply of and provide the requested dosage information.
10. Before submitting, ensure the form is signed and dated by the prescriber. This step is crucial for processing the form. Include any additional required forms as specified in the instructions.
11. Finally, save your changes, download the completed form, print it, or share it electronically as needed.

Complete your forms online today to streamline the patient enrollment process.