Get Wound Care - Encompass Rx

The Wound Care - Encompass RX form is essential for ensuring that patients receive the appropriate wound care medications in a timely manner. This guide provides clear, step-by-step instructions to help you accurately complete the form online.

Follow the steps to complete the Wound Care - Encompass RX form.

1. Press the ‘Get Form’ button to obtain the Wound Care - Encompass RX form and open it in your document editor.
2. Fill out the date needed by section to indicate when the medications are required.
3. Complete the patient demographics section with the patient’s last name, first name, date of birth, and contact information including their street address, city, state, zip code, and phone numbers.
4. Attach a copy of the front and back of the patient’s prescription insurance card within the designated section.
5. Provide the primary prescription insurance name, Rx BIN, patient ID/Policy number, and patient Rx group number.
6. In the patient clinical information/history section, attach a copy of the patient’s recent chart notes, pathology, and lab results, and include the appropriate ICD-10 codes.
7. Indicate whether the patient is a burn patient.
8. For each wound location, enter the size in centimeters (cm) for wounds 1 through 4 and record the prescriber’s National Provider Identifier (NPI).
9. Provide any additional clinical information such as drug allergies and current medications, including whether the patient is using or any dressing containing Silver or Iodine.
10. Fill in the home health referral information, including details of the referring agency and provider.
11. Under prescription information, document the drug and directions for use, along with the quantity and number of refills needed.
12. Complete the prescriber information, including their name, facility, contact information, NPI, DEA, and secure the physician’s signature.
13. Once all sections are filled out, review the form for accuracy. You can save changes, download, print, or share the form as required.

Complete your documents easily online today.