Get Services Request Form - Needymeds - Needymeds

The SERVICES REQUEST FORM - NeedyMeds allows users to request various services related to medical support. This guide will provide clear and supportive instructions to assist in completing the form effectively online.

Follow the steps to complete the SERVICES REQUEST FORM correctly.

1. Begin by clicking the ‘Get Form’ button to access the SERVICES REQUEST FORM. This action will open the document in your preferred editing format, allowing you to fill out the necessary information.
2. In the 'SERVICES REQUESTED' section, check all applicable boxes for the services you are requesting, such as Benefits Investigation and Patient Assistance Program (PAP).
3. Next, move to the 'PATIENT INFORMATION' section. Fill in the last name, first name, date of birth, and gender. Provide the street address, city, state, home and work/cell phone numbers, email address, and alternate contact information.
4. Proceed to 'INSURANCE INFORMATION'. Enter the names of your primary and secondary insurance providers and their respective contact phone numbers. Include the Policy ID numbers and group numbers. Make sure to specify the policyholder's information and confirm that you have attached legible copies of the front and back of all insurance cards.
5. Continue with the 'PRESCRIBER INFORMATION' section. Enter the prescriber’s first and last names, practice name, specialty, and office contact details. If the administering site is different from that of the prescribing physician, provide those details as well.
6. In the 'PRESCRIPTION INFORMATION' section, indicate whether this is a new prescription, a continuation, or a restart. Fill in details such as diagnosis, medication strength, dosage form for , and treatment date.
7. Complete the 'PRESCRIBER DECLARATION' by having the prescriber sign and print their name, along with the date. This section certifies that the prescription is for the listed patient.
8. In the 'PATIENT AUTHORIZATION AND RELEASE TO COLLECT, USE, AND DISCLOSE MEDICAL INFORMATION', the patient or authorized representative must read and sign to authorize the necessary disclosures.
9. For PAP applicants, provide the required annual income and number of family members living in the household. Remember to include verification of income.
10. Finally, if you wish to receive educational support from GSK, check the corresponding box and provide the email address. Ensure that the form has been saved and review all entries before sending.

Complete your SERVICES REQUEST FORM online and ensure you receive the benefits you need.