Get Dr Akiyomi Fields

Filling out the Dr Akiyomi Fields form online is a straightforward process that requires careful attention to detail. This guide serves to provide users with step-by-step instructions to ensure that all necessary information is accurately completed.

Follow the steps to effectively complete the Dr Akiyomi Fields form.

1. Click ‘Get Form’ button to access the Dr Akiyomi Fields document and open it in your preferred editor.
2. Begin by entering the patient information. Fill in the patient’s name, member number, and date of birth accurately. Ensure that all the details provided match the insurance records.
3. In the drug name requested section, check the appropriate box for the treatment option being requested. This includes preferred and non-preferred products.
4. Complete the qualification criteria by checking all applicable boxes. Acknowledge whether the patient has a confirmed diagnosis of Partial Androgen Insensitivity Syndrome, hypogonadism, or any specified symptoms.
5. Input the required levels. Ensure to include the first and repeat levels along with the dates of testing. Attach lab results that provide reference ranges.
6. If applicable, document any symptoms from both specific and non-specific categories, ensuring chart notes are attached to verify those symptoms.
7. If requesting non-preferred agents, confirm that the patient has previously tried and failed the preferred options, by checking the appropriate boxes.
8. Finally, provide prescriber information. Fill in the prescriber’s name, ensure they sign the form, and include relevant contact information such as phone number, fax number, and DEA/NPI number.
9. After completing the form, review all entries for accuracy. Save any changes made, and choose the option to download, print, or share the completed form as necessary.

Complete your documents online today for an efficient filing experience.