Get Corlanor Ready Intake Bformb

This guide provides clear instructions on how to accurately complete the Corlanor Ready Intake BFormb online. Follow each step carefully to ensure all necessary information is submitted correctly.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it in the designated online editor.
2. Begin by entering the patient information. This includes the patient’s name, street address, city, state, zip code, telephone number, date of birth, and social security number. Ensure each required field is clearly filled out.
3. In the prior treatment history section, specify any beta-blockers the patient has taken. If applicable, indicate the beta-blocker dose and whether the patient is stable on the maximum tolerated dose. Mark ‘Yes’ or ‘No’ as required, and provide reasons if the patient is not on a beta-blocker.
4. For pharmacy insurance information, attach a copy of the insurance card (front and back) and input the Pharmacy Insurance ID number and telephone number.
5. If pharmacy insurance information is unavailable, fill out the medical insurance information section. Provide the name of the insurer, their telephone number, subscriber name, date of birth, relationship to the patient, group number, and policy number. Attach the insurance card as well.
6. If there is secondary medical insurance, repeat the process for this section, including attaching the necessary insurance card.
7. In the patient medical information section, provide a primary ICD-10 code as well as any additional relevant medical history. Fill out the resting heart rate and whether the patient is in sinus rhythm, including their left ventricular ejection fraction.
8. Complete the prescription information section stating the product name, dosage/strength, days’ supply, and refill details. Ensure all required fields are filled in accurately.
9. Next, provide prescribing physician information including their contact details, name, specialty, office name and address, and their NPI number. Fill in any payor-specific provider numbers if applicable.
10. Lastly, the prescribing physician must review the form, sign, and date it. Ensure all required sections are complete to facilitate the processing of the information.
11. Once the form is thoroughly completed, you may save changes, and consider downloading, printing, or sharing the form as needed.

Complete the Corlanor Ready Intake BFormb online and ensure accurate submission to expedite your process.