Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the document and open it in the editor.
2. Begin by filling out the 'Ordering Provider' section. Enter the first name, middle initial, and last name of the provider. Include the provider's date of birth, gender, and contact information, including the street address, city, state, and zip code.
3. Next, complete the 'Patient/Member' section. Include the patient's first name, last name, home phone, and cell phone numbers. Document the patient's health plan and member ID as well.
4. In the 'Diagnosis' section, provide the diagnosis details, including any known conditions and the relevant ICD-10 codes. Capture the date of the last visit to the healthcare provider.
5. Fill in the 'Procedure' section by listing all applicable CPT codes for the requested service. Indicate the level/muscle group, specify if it is right, left, or bilateral, and plan the procedure date.
6. Answer the follow-up questions regarding the service relationship, requested site of service, and any medications to be injected. Include information on previous injections, their procedure dates, and outcomes.
7. Proceed to provide clinical information, including patient history, physical findings, imaging dates and results, and any prior therapies.
8. In the final sections, detail the follow-up plan, the presence of co-morbidities, and any additional comments or information that might be relevant.
9. After completing the form, ensure that all sections are filled accurately. You can then save changes, download, print, or share the completed form as needed.

Complete your Musculoskeletal Solution Evidence-based Medicine EviCore form online today for efficient processing.