Follow the steps to fill out the VNS Therapy eligibility and education form correctly.

1. Click ‘Get Form’ button to acquire the form and open it in the appropriate editing format.
2. Begin with the requesting physician information section. Enter the physician's name, NPI number, phone number, as well as the surgeon's name, NPI number, phone number, date of surgery, and implanting hospital in the provided fields.
3. Next, fill in the patient information section. Input the patient's first and last name, address (city, state, zip), sex, phone number, social security number, date of birth, guardian or contact person's name, email, and, if applicable, the group home name.
4. Identify the principle diagnosis by checking the relevant box for the corresponding code, ensuring to select accurately according to the patient's condition. If none of the provided options apply, select 'Other' and provide a brief description.
5. In the insurance information section, indicate whether the patient face sheet is attached by selecting 'Yes' or 'No'. If 'Yes', include details of the primary and secondary insurance companies, including their names, phone numbers, subscriber's name (if applicable), employer/plan name, policy number, group number, provider insurer ID number, and whether the physician participates with the above insurer.
6. Authorize the release of information by signing where indicated. This includes allowing LivaNova, Inc. to share details with insurers and have a VNS Therapy nurse case manager contact the patient for education purposes.
7. If the patient is an authorized representative or legal guardian, ensure that the relevant section is signed by the patient or legal guardian. This authorization allows the physician to disclose protected health information as required.
8. Finally, review all provided information for accuracy before saving changes, downloading, printing, or sharing the completed form.

Complete your VNS Therapy eligibility and education form online today to ensure timely access to necessary treatment.