Get Sample Program Form

This guide provides clear and detailed instructions on completing the Sample Program Form online. Whether you are a first-time user or need a helpful reminder, this step-by-step process is designed to assist you in accurately submitting your information.

Follow the steps to complete the Sample Program Form online effectively.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. Fill out Section A with the patient's information, including their name, date of birth, contact phone number, email, and address. Ensure the information is current and accurately reflects the patient's details.
3. Provide the diagnosis using the ICD-10 code and specify any known drug allergies or confirm there are none.
4. In Section B, enter prescriber information such as the prescriber's name, facility name, state license number, address, and contact information. Ensure this is complete to avoid delays in processing.
5. Section C requires prescription information including the current Ig brand, patient weight and height, and details about the dosing schedule. Be thorough, especially regarding the total dose and infusion schedule.
6. Check Section D to determine if infusion training is requested. If so, ensure the appropriate box is checked. This section requires the prescriber's signature and date.
7. In Section E, include the prescriber's authorizations. A signature is needed to certify that the treatment is necessary and that the patient is suitable for self-administration.
8. After ensuring all sections are filled out completely, save your changes. You can download the form, print it, or share it as needed. Remember that the completed form must be submitted via fax or encrypted email.

Complete your Sample Program Form online today to ensure timely processing of your request.