Get Piq Pdf

Filling out the Piq Pdf form is an essential step in the process for eligibility and education regarding VNS Therapy. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Piq Pdf form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering the requesting physician's information. Fill in the physician's name, NPI number, address, and phone number. Also, provide the surgeon's name, NPI number, address, and phone number, along with the implanting hospital and date of outpatient surgery.
3. Next, complete the patient information section. Enter the patient’s last name, first name, address, phone number, sex, city, state, zip code, date of birth, social security number, and email. If applicable, provide the guardian or contact name and the group home name.
4. Indicate the principal diagnosis by checking the appropriate box, specifying if it is partial epilepsy with or without impairment of consciousness, or if there is another diagnosis, please provide a description.
5. In the insurance information section, input details for both primary and secondary insurers, including the name of the insurance company, phone number, subscriber's name (if different), employer/plan name, policy number, group number, and provider insurer ID number.
6. Confirm the physician's participation with the insurer by marking 'Yes' or 'No' for both primary and secondary insurers.
7. Review the authorization statements carefully, ensuring all necessary sections are signed by both the physician and, if required, the patient or legal guardian.
8. Finally, save your changes, and download, print, or share the completed form as required.

Complete your documents online to streamline the process.