Get Mobilex Fax Form2015docx

This guide provides clear instructions for users on how to effectively complete the Mobilex Fax Form2015docx online. By following these steps, you will ensure a smooth process for ordering portable x-ray services through MobilexUSA.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to access the Mobilex Fax Form2015docx and open it in your chosen editor.
2. Begin filling out the form by entering the claim number and date at the top, ensuring all entries are completed in print to avoid any delays.
3. Select the urgency of the referral service by checking the appropriate box for 'Same Day', 'Routine', or 'Appointment' per your needs.
4. Provide your customer account number, customer name, and contact information in the designated fields to ensure proper identification.
5. Fill out the patient’s name, gender, social security number, date of birth, and address thoroughly to validate the order.
6. Indicate the patient's phone number and any alternative contact numbers for further communication.
7. Complete the section for hospice coverage, filling in the carrier information and selecting whether hospice is covered or not.
8. Enter insurance details including Medicare number, Medicaid number, and any other applicable insurance policy information.
9. In the exam order section, specify the type of x-ray or ultrasound required along with the number of views and the reason/symptom prompting the examination.
10. Complete the condition of the patient section that explains why portable x-ray services are necessary, ensuring all required information is provided.
11. At the end of the form, fill in the ordering practitioner's name, date, contact phone and fax numbers, and obtain the required signature.
12. Review all information for accuracy, and ensure any special instructions or additional details are included before moving on.
13. Save your changes, then download, print, or share the completed form as needed to send to MobilexUSA.

Complete your documents online today for a streamlined service experience.