Get Fax A Completed Xofigo Access Services Intake Form Including The Signed Patient Authorization (page

Filling out the Xofigo Access Services Intake Form correctly is crucial for ensuring effective treatment scheduling and insurance verification. This guide provides a clear and comprehensive approach to completing the form online.

Follow the steps to successfully complete the intake form.

1. Click ‘Get Form’ button to obtain the form and open it in the editing environment.
2. Carefully enter the administering provider information, including the provider's name, specialty, and identification numbers. Ensure that all fields are filled out accurately.
3. Provide the product shipping information by specifying the ship-to facility name, address, and contact details. This is essential for the timely delivery of Xofigo.
4. Complete the patient information section with the patient's name, address, contact details, and relevant insurance information. Make sure to include primary and secondary insurance details.
5. List the treatment dates and times, ensuring that at least the first treatment date is provided. This helps in scheduling and coordination.
6. Fill out the referring provider information, which is important for keeping other healthcare providers informed about the treatment.
7. Sign the physician declaration to confirm the accuracy of the information provided, which is crucial for compliance and accountability.
8. Complete the patient authorization section. Ensure that the patient or their representative signs and dates this section to permit the use and disclosure of health information.
9. Once all sections are duly filled, save your changes. You can then download, print, or share the completed form as needed.

Take the next step by completing your documents online to streamline your Xofigo application process.