Get Single Patient Lab Reporting Form New

This guide provides a comprehensive overview of how to effectively complete the Single Patient Lab Reporting Form New online. Step-by-step instructions will help you navigate each section of the form to ensure accurate and timely submission.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and access it within your editor.
2. Fill in the patient information section. This includes the patient's initials, social security number, eligibility code or patient ID, full name, zip code, date of birth, sex, and monitoring frequency (weekly, bi-weekly, or monthly).
3. Next, provide the laboratory results. Enter the total WBC count and ANC value along with the date the blood was drawn. Ensure to check if the counts are acceptable for dispensing as noted in the prescribing reminders.
4. In the therapy status section, indicate if the treatment is pre-treatment, active, interrupted, or discontinued.
5. Input dosage information by providing the total mg/day administered and the dispense date, clearly noting the month, day, and year.
6. Complete the treating physician's information by entering the physician's name, DEA/ID number, medical facility name, address, city, state, telephone number, and zip code.
7. Provide the dispensing pharmacy details, including the pharmacist's name, pharmacy DEA/ID number, pharmacy name, address, city, state, telephone number, and zip code.
8. Finally, ensure to submit the completed form to the Teva Patient Registry and keep a copy for your records. After filling out all sections, you can save changes, download, print, or share the form as required.

Ensure your lab results are submitted accurately and timely by completing the Single Patient Lab Reporting Form online today.