Get Xofigo Access Services Intake Form

Filling out the Xofigo Access Services Intake Form is an important step in facilitating patient treatment and insurance verification. This guide provides a comprehensive and user-friendly approach to completing the form online, ensuring that users can navigate each section with confidence.

Follow the steps to effectively complete the form.

1. Click ‘Get Form’ button to obtain the form. Open it in your device's preferred document editor.
2. Begin with the 'Administering Provider Information' section. Fill in required fields such as administering provider name, specialty, NPI number, and tax ID number. Ensure all information is accurate to avoid delays.
3. Provide your facility information, including the facility name and address. Check the appropriate box that describes the facility type, such as hospital outpatient or free-standing clinic.
4. In the 'Administering Site Contact(s)' section, include the names and titles of contacts for benefit verification and order placement. This will help ensure smooth communication regarding the patient's treatment.
5. Enter the 'Product Shipping Information.' Specify the ship-to facility name, address, and the receiving contact's name to facilitate accurate delivery.
6. Complete the 'Patient Information' section. Input the patient's name, address, phone number, and date of birth. Provide accurate insurance information as it is crucial for verification.
7. Fill in the 'Treatment Dates/Times' by providing the patient's first treatment date at minimum. This information is essential for scheduling and planning.
8. In the 'Referring Provider Information' section, enter the referring provider's name and facility information to assist with future communication regarding the patient's treatment updates.
9. Review the 'Physician Declaration'. This is important for affirming the accuracy of the information provided in the form. Ensure you sign and date this section.
10. Finally, if applicable, complete the 'Patient Authorization for Xofigo Access Services'. Ensure all relevant signatures are obtained. Once completed, save your changes and choose to download, print, or share the form as needed.

Complete the Xofigo Access Services Intake Form online to facilitate timely patient care and insurance verification.