Follow the steps to fill out the 18883433547 form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor. This will allow you to access the necessary fields for completion.
2. Provide the patient information in the specified fields. Enter the first name, last name, middle initial, member ID, and date of birth. Please also indicate the patient's gender and if they are transitioning from a facility.
3. Fill in the provider information. Enter the provider's first name, last name, NPI number, address, phone number, fax number, office contact, and specialty.
4. In the medication and medical dispensing information section, provide details including the medication name, strength, diagnosis/ICD10 code, frequency, quantity, refills, and route of administration.
5. Answer the questions regarding the medication's status, including whether it is new or a continuation of therapy, and whether dose titration is required.
6. Complete the clinical information section. Indicate if the drug is used for an FDA-approved indication and provide any necessary details about preferred/formulary drugs the patient has experienced treatment failures with.
7. Attach any relevant lab results, tests, and diagnostic studies that support the use of the therapy. Ensure you check the box indicating that documentation is attached if applicable.
8. Complete the attestation statement, ensuring accuracy of the information provided. The prescriber must sign and date the form.
9. Review all filled fields to ensure accuracy and completeness. Save any changes and consider downloading or printing the form for your records.
10. Finally, submit the completed form along with any required documentation to the appropriate health plan.

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