Follow the steps to complete the form online.

1. Click the ‘Get Form’ button to access the 2016 Fax Order Form. This will open the document for you to complete it in a user-friendly manner.
2. Begin by entering the patient information in the designated fields. Include the patient's name, date of birth, and contact telephone numbers for daytime and evening. Ensure you fill in the city, state, and zip code accurately.
3. Next, provide the physician’s information. Fill out the name, address, telephone number, and fax number of the prescribing physician to guarantee seamless communication regarding the medical order.
4. Complete the patient insurance information section. Indicate the type of insurance by checking the appropriate box (Medicare, Medicaid, or private insurance). Provide the NPI, insurance policy number, group number, and insurance telephone number.
5. If applicable, include the patient’s secondary insurance information. Fill out similar details as in the previous step for efficient processing.
6. Select the payment method for non-covered items by checking the relevant option and providing necessary credit card information if choosing that payment method.
7. Indicate which items you need to order by checking all applicable boxes in the supplies section. Include the product number, description, and quantity for each selected item.
8. Before finalizing your order, ensure you attest to the prescriber signature by checking the corresponding box. Lastly, download, print, or share the completed form as necessary.

Complete your forms online today for a seamless ordering experience!