Get Patient Enrollment Form

Filling out the Patient Enrollment Form online is a straightforward process that allows you to provide essential information for your medical needs efficiently. This comprehensive guide will lead you step-by-step through each section of the form to ensure a smooth experience.

Follow the steps to complete the Patient Enrollment Form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In the 'Patient Information' section, enter your full name, date of birth, and address. Ensure that you check for typos and confirm the accuracy of your provided details.
3. In the 'Insurance Information' section, fill in the primary and, if applicable, secondary insurance carrier details, including health plan, phone number, ID number, and group number. Specify the policy holder's name, date of birth, relationship, and gender.
4. Provide the prescriber’s information, including the prescriber’s name and National Provider Identifier (NPI). If the prescriber is new, select the option indicating they are a first-time prescriber.
5. Complete the 'Administering Facility' details by entering the facility name, city, and state where services will be provided.
6. Select the purpose of the PET scan imaging by checking the appropriate box. You may also provide an alternative purpose in the space provided.
7. In the 'Clinical Information' section, select the applicable ICD-10 codes that correspond to the somatostatin-bearing neuroendocrine tumors. Multiple selections can be made if necessary.
8. Choose the appropriate CPT codes related to the PET scan and the administration of the radiopharmaceutical injection, selecting only one code from each list.
9. Read and understand the patient consent section carefully, as it outlines the authorization for sharing personal health information. Sign and date the form where indicated.
10. Finally, review all the information entered to ensure accuracy and completeness. Once verified, save the changes, and you can download, print, or share the completed form as needed.

Start filling out the Patient Enrollment Form online today to streamline your medical assistance process.