Get ( Pegol) Injection Referral Checklist

Completing the (Pegol) injection referral checklist online can be a straightforward process with the right guidance. This guide will provide you with clear, step-by-step instructions to ensure that you accurately fill out each section of the form.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the document and open it in the editing platform.
2. Begin by entering the patient's name in the designated field at the top of the form.
3. Next, fill in the date of referral and the patient's date of birth (DOB) in the appropriate fields.
4. Provide the referring physician's name along with the referring office's contact details, including phone number and fax number.
5. Input the address of the referring office in the specified section.
6. Indicate the diagnosis pertinent to the referral, followed by the corresponding ICD code.
7. Detail the dose and frequency of the treatment in the next section, ensuring all instructions are clear.
8. Add any special instructions for the treatment in the special instructions field, including any specific requirements for the patient.
9. Take a moment to review the list of required documents and records, ensuring you have checked each item as you prepare to submit alongside this form.
10. Finally, ensure that you fax the completed form along with the requested documents to the provided fax number, using this form as the coversheet.

Start outlining your checklist today to streamline the referral process!