Get Statement Of Medical Necessity Form. Use This Form To Enroll Patients In Access

This guide provides a comprehensive approach to filling out the Statement Of Medical Necessity Form, a crucial document needed for enrolling patients in Access. By following the detailed steps outlined below, users can effectively complete the form to ensure proper enrollment and support for their patients.

Follow the steps to successfully complete the Statement Of Medical Necessity Form.

1. Click the ‘Get Form’ button to obtain the Statement Of Medical Necessity Form and open it for editing.
2. Fill out the patient information section. Input the last name, first name, street address, date of birth, city, home phone number, work/cell phone number, state, zip code, email address, preferred language (if applicable), alternate contact name, relationship to the patient, and alternate phone number.
3. In the Insurance Information section, indicate if the patient has insurance. Provide the names of primary and secondary insurance, their phone numbers, subscriber names, and ID and group numbers as required.
4. Complete the Diagnosis Information by marking the appropriate option related to idiopathic pulmonary fibrosis or another diagnosis provided by an ICD-10 code.
5. Fill out the prescriber information, including the last name, first name, street address, suite number, practice name, city, state, prescriber NPI number, and fax number.
6. In the Prescription Information section, select the initial tablet titration details and provide any other special instructions needed for the patient's treatment plan.
7. In the Start Now Program section, indicate approval for a complimentary 30-day supply of if necessary, based on eligibility criteria.
8. Finally, ensure the prescriber certifies by signing and dating the form. The original signature is crucial for processing, and the completed form must be faxed to the designated number.

Complete the Statement Of Medical Necessity Form online today to ensure your patients receive the care and support they need.