Get Patient Information Form - Finder

This guide provides clear instructions on how to complete the Patient Information Form - Finder online. It outlines each section and field to help users efficiently gather and submit their information.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Patient Information Form - Finder and open it in the document editor.
2. Fill in the pharmacy information at the top of the form, including the pharmacy name, fax number, and attention line.
3. Provide patient information by entering the patient's full name, address, city, state, ZIP code, work phone, cell phone, social security number, and date of birth.
4. Complete the physician information section by entering the physician's name, specialty, site name, address, city, state, ZIP code, phone number, fax number, email address, office contact, and National Provider Identifier (NPI).
5. In the pertinent medical information section, mark the applicable medical history, including any relevant ICD-10 codes, T-scores, and the skeletal site if known. Specify any other risk factors or relevant medical history as required.
6. Indicate the history of prior osteoporosis therapy, if any, by marking the relevant options and providing reasons for discontinuation and any contraindications.
7. Fill out the insurance information section. If you are a Medicare patient, attach a copy of the insurance card; otherwise, provide the insurer's name, policy number, patient ID, and insurance phone number.
8. Specify the prescription information, including the product name, directions, refills needed, state license number, and DEA number. Choose the shipping option.
9. Ensure that the prescriber signs the form and dates it at the bottom before submission.
10. Once all fields are completed, save changes, download, print, or share the form as needed.

Complete your Patient Information Form - Finder online today to ensure your medical needs are promptly addressed.