Get Nebulizer Order Form

This guide provides step-by-step instructions on how to complete the Nebulizer Order Form online. By following the outlined steps, users will easily navigate the form and ensure all necessary information is accurately provided.

Follow the steps to successfully complete the Nebulizer Order Form

1. Press the ‘Get Form’ button to access the Nebulizer Order Form and open it in your preferred online form editor.
2. Enter the date at the top of the form to indicate when the request is being submitted. This should be the current date.
3. In the Physician Information section, fill in the physician's name, NPI number, DEA number, physician state license number, office phone number, and office address. Ensure all fields are completed to prevent processing delays.
4. Next, proceed to the Member Information section. Here, include the member's name, date of birth, IEHP ID, contact phone number, and address.
5. In the Nebulizer section, specify the nebulizer type as 'PulmoMate' and the NDC number as '16958-0684-58'.
6. Complete the Sig field by writing 'As Directed' to provide prescription instructions.
7. Finally, sign the form in the designated signature area to validate the request.
8. Once all sections are filled out, save your changes to the form. You may also choose to download, print, or share the completed form as needed.

Complete your Nebulizer Order Form online today for efficient processing.