Get Referral Form Fax - Duncan Prescription Center

Filling out the Referral Form Fax for Duncan Prescription Center is a straightforward process, designed to facilitate the prescription of . The following guide provides clear, step-by-step instructions to help users complete the form efficiently and accurately.

Follow the steps to fill out the Referral Form Fax online

1. Press the ‘Get Form’ button to access the Referral Form Fax and open it in the designated application.
2. Complete the prescriber information section. Include the prescriber’s name, state license number, DEA number, phone number, facility name, address, fax number, and NPI number.
3. Fill in the patient information. Provide the patient's name, date of birth, preferred phone contact number, email address, and address details including city, state, and zip code.
4. Select the patient’s gender and provide their social security number. Enter the patient’s diagnosis by including the relevant ICD-10 codes for alcohol and opioid dependence.
5. In the injection provider information section, indicate whether your office will be administering . If not, provide the details of the facility that will handle the administration.
6. Outline any medications the patient has previously tried and failed, ensuring to include that information for the provider.
7. Provide patient insurance information, making sure to attach a copy of both sides of the patient’s insurance cards. Fill in the pharmacy benefit plan name and phone number, policyholder name, policy number, and any relevant Rx codes.
8. In the prescription information section, specify the dosage of required and the number of refills.
9. Obtain the prescriber’s signature in the designated area and date the form. Ensure that the signature matches the prescriber’s name provided earlier.
10. Review the completed form for accuracy. Save the changes, and download, print, or share the form as needed.

Complete your documents online to streamline the referral process.