Get Injectafer Fax Referral Form

Filling out the Injectafer Fax Referral Form online is a straightforward process that ensures accurate and timely referral of patients for treatment. This guide provides detailed instructions to help you navigate each section effectively.

Follow the steps to fill out the form online

1. Press the ‘Get Form’ button to access the Injectafer Fax Referral Form and open it in your preferred digital editor.
2. Begin by filling out the patient demographics section. Include the patient's full name, date of birth, and contact phone number accurately to ensure proper identification.
3. Provide the patient's allergies, if any, to alert the medical provider to avoid any potential adverse reactions.
4. Fill in the primary diagnosis using the ICD-9 codes. Common entries include '280.0' for iron deficiency anemia and '280.8' for unspecified anemia. Include a secondary diagnosis if applicable, such as 995.20 for an adverse effect of a biologic drug.
5. Complete the section for medical necessity by detailing any additional diagnoses that support the referral, making sure to use the appropriate ICD-9 codes.
6. In the prescription orders section, specify the treatment details: state 'Injectafer® (ferric carboxymaltose) 750mg/15ml single use vial' and include the administration schedule (e.g., 'Give 750mg/15ml IV over 30 minutes once a week for ___ doses').
7. Note any premedications required prior to the treatment in the provided space, ensuring comprehensive instructions.
8. Enter the physician's information, including their name, phone, and fax number, to facilitate communication regarding the referral.
9. Sign and date the form where indicated to confirm the authenticity of the referral.
10. Finally, save your changes, and once you're satisfied with the completed form, you can download, print, or share it as needed. Remember to fax the completed form to (214) 887-0436.

Complete your referral forms online today for a seamless submission process!