Get Insurance Verification Request Form - Injectafer

Filling out the Insurance Verification Request Form for Injectafer is a crucial step in ensuring that insurance coverage can be confirmed for the patient. This guide provides clear, professional instructions to assist users in completing the form accurately and efficiently online.

Follow the steps to successfully complete the Insurance Verification Request Form.

1. Press the ‘Get Form’ button to obtain the form and access it in the editing interface.
2. Fill in the contact information for the person completing the form, including their name and phone number.
3. In the Patient Information section, ensure that the patient's consent is indicated. Mark 'YES' or 'NO' regarding consent on file and fill out the patient's name, address, phone number, date of birth, and social security number.
4. Provide relevant medical information, including the requested product (either or Injectafer), primary and secondary diagnoses, and the setting of care (e.g., physician's office or hospital outpatient). Specify the anticipated date of service.
5. Fill in the Primary Insurance section with the insurer's name and state, indicating whether the provider participates. Include payer provider number, contact numbers, policy holder's details, and policy and group/plan numbers.
6. If applicable, complete the Secondary Insurance section in the same manner as the Primary Insurance, ensuring all required fields are filled accurately.
7. In the Physician Information section, enter the prescribing physician's name, NPI number, tax ID, facility name, address, specialty, and contact numbers. Also include the DEA number if applicable.
8. Indicate if you would like to initiate the prior authorization process by marking 'YES' or 'NO'.
9. Once all sections are completed, review the form for accuracy, and save your changes. You can then download, print, or share the completed document as needed.

Complete the Insurance Verification Request Form online to ensure timely insurance verification for Injectafer.