Get Patient Forms

Filling out the Patient Forms online is essential for ensuring a smooth and efficient process in obtaining insurance coverage for . This guide will provide clear instructions tailored to your needs, helping you navigate each section of the form with confidence.

Follow the steps to complete the Patient Forms online:

1. Click the ‘Get Form’ button to access the Patient Forms and open it in your document editor.
2. Begin by reviewing the 'Patient Consent' section. Here, you will need to provide your signature and the date, certifying that you have obtained valid consent from the patient for the release of their protected health information.
3. Fill out the 'Patient Information' section. Provide the patient's last name, first name, middle initial, address, city, state, daytime phone number, alternate phone number, email, date of birth, and social security number.
4. Enter the primary insurance details. If you have copies of the insurance card, you may attach them instead of filling this section out. Include the policyholder’s name, group number, policy number, provider ID, insurance contact, and phone number.
5. If applicable, complete the 'Secondary Insurance' section with the same details as the primary insurance, including the policyholder's information and the relationship to the patient.
6. Proceed to the 'Physician Information' section. Fill out the physician's name, anticipated initial injection date, diagnosis, specialty, treatment setting, practice name, and address. Also include the NPI number, DEA, and tax ID number.
7. In the 'Clinical Information' section, specify the number of MP and PIP joints to treat for both the left and right hand, noting that up to 3 injections can be performed per joint.
8. Fill out the 'Rx Information' section with the prescription details, including the Physician ID, Healthcare Site ID, and dosage instructions. Note any requests for syringes or other supplies.
9. Ensure that all information is accurate and complete, then sign where indicated, verifying the prescription and providing the date.
10. Finally, review your completed form. Save your changes, and utilize the options available to download, print, or share the form as necessary.

Complete your Patient Forms online today to streamline your access to insurance coverage.