Get 877 287 3631

This guide provides clear and supportive instructions on how to complete the 877 287 3631 form online. Users with varying levels of experience will find the step-by-step process easy to follow.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the patient information section. Include the patient's name, address, sex, and date of birth. Ensure that you select the appropriate box for gender.
3. Provide the patient's phone number, Social Security number, and complete any required demographic details.
4. Complete the emergency contact section, including their phone number to ensure immediate communication if necessary.
5. Document the diagnosis accurately to assist in evaluating eligibility for the AIM program.
6. In the physician section, enter the name of the ordering or following physician, along with their contact information including phone number and fax number.
7. Indicate the necessary orders for evaluation and treatment under AIM, emphasizing the patient's qualifying conditions.
8. Obtain the ordering physician's signature to validate the referral. Ensure the signature is completed before submitting the form.
9. Once all fields are filled, save the changes, download the completed form, and prepare to fax it to (877) 287-3631, including all required attachments such as the signed referral form, proof of insurance, demographics, and recent progress notes.

Complete your forms efficiently online today!