Get Injectable Psychotropic Medication Enrollment Form - Briovarx

Filling out the Injectable Psychotropic Medication Enrollment Form - BriovaRx online can streamline the process of enrolling for medication. This guide provides clear, step-by-step instructions to assist users in accurately completing the form.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to initiate the process and access the Injectable Psychotropic Medication Enrollment Form.
2. Begin by filling out the patient information section. This includes the patient’s name, birth date, and social security number, along with their insurance ID, height, weight, and contact details. Ensure all information is correct and complete.
3. Provide details about the prescribing physician. This section requires the physician's name, National Provider Identifier (NPI), address, and contact numbers.
4. Complete the primary and secondary insurance information sections. Make sure to enter the insurance company's name and phone number, along with the subscriber's name, ID number, and group number. Do not forget to attach copies of the front and back of the member’s insurance card.
5. Fill out the location of administration and shipping information, including the address where the medication will be administered, the NPI, and any specific shipping instructions required.
6. Provide diagnosis information by entering the relevant ICD-10 code and diagnosis details. Indicate the medications required along with their respective doses and instructions.
7. Ensure to review and authorize the prescriber authorization section, permitting the pharmacy to act as the authorized agent, and ensure all required signatures are obtained.
8. In the patient authorization section, the patient or their authorized representative should provide a signature, approving BriovaRx Specialty Pharmacy to bill the insurance. Confirm understanding of financial responsibilities for costs not covered by insurance.
9. Finally, review all entries for accuracy, and complete any remaining required fields. Users can then save changes, download the completed form, print it, or share it as needed.

Take the next step toward medication enrollment by completing the form online today.