Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Begin by entering the patient's name in the specified fields, ensuring that you accurately include the last name. Follow up by entering details for the prescriber, including their first name, middle initial, and last name.
3. Input the date of birth of the patient in the format MM/DD/YYYY. This information is vital for accurate prescribing.
4. Complete the prescriber address section. Fill in the street address, city, state, and zip code along with their 10-digit National Provider Identifier (NPI) number and West Virginia Medicaid 11-digit ID number.
5. Fill in the phone number and fax number for the prescriber to ensure clear communication.
6. If applicable, provide the name and address of the pharmacy, including the 10-digit NPI number for the pharmacy.
7. Next, you will need to detail the medication being requested. Fill in the drug name, strength, route of administration, and specific directions for use.
8. Include the diagnosis and, if available, the ICD diagnosis code associated with the prescription.
9. Respond to the questions regarding the patient's treatment history and any conditions preventing the use of preferred products by indicating 'yes' or 'no'. Provide additional details where needed.
10. As you near the end, you must provide your signature, either manually or electronically, to attest that the request is medically necessary. Ensure to input the date on which the form is being signed.
11. Finally, review all your entries for accuracy and completeness. Once finalized, users have the option to save changes, download, print, or share the form.

Start filling out the Rational Drug Therapy Phone Number form online today for seamless processing.