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

This guide provides clear, step-by-step instructions on how to accurately complete the Statement Of Medical Necessity Form for enrolling patients in Access. By ensuring all required fields are properly filled, delays can be avoided, facilitating a smoother enrollment process.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it in the editor for completion.
2. Fill out the patient information section. Include the patient's last name, first name, birth date, address, and contact numbers. Indicate if contact with the patient is permitted.
3. Provide the patient’s insurance details. Specify the primary and secondary insurance information if applicable, including name, policy numbers, and anticipated treatment date.
4. In the diagnosis/treatment section, check the appropriate diagnosis codes and specify whether the diagnosis is primary or secondary. Ensure to select the eye(s) being treated.
5. Complete the prescription section. Ensure all dosing instructions and prescriptions for are filled clearly, indicating the required quantity and method of administration.
6. Complete the prescriber information section. Include prescriber’s name, practice details, contact information, and ensure to provide the necessary signatures.
7. Attach the signed Patient Authorization and Notice of Release of Information (PAN) form. If the patient is insured, include a front and back copy of their drug card.
8. Review the completed form to ensure all required fields are filled clearly and legibly to prevent delays in processing.
9. Save changes, then download, print, or share the completed form as needed for submission.

Complete your documents online to ensure a smooth enrollment process.