Follow the steps to fill out the form effectively.

1. Begin by pressing the ‘Get Form’ button to download the form, which will allow you to open it in a suitable online editor.
2. Input patient information in the designated fields, including the patient's first name, last name, middle initial, date of birth, and sex. Be sure to accurately record any drug allergies.
3. Provide prescriber information, including the prescriber's name, specialty, NPI, state license number, and office contact information. Ensure all contact numbers are correct for seamless communication.
4. Indicate the primary and secondary insurance details, filling in the cardholder ID, group number, and policyholder name as they appear on the insurance documents.
5. Detail the diagnosis for which DEPOT is being prescribed by selecting the appropriate checkbox (e.g., endometriosis, fibroids) and entering the corresponding ICD-10 codes.
6. Select the prescription type for DEPOT or LUPANETA PACK and specify the shipping preference, indicating whether the medication should be delivered to the prescriber or the patient.
7. Complete the prescription details, including dosage and frequency of administration, ensuring you specify the quantity and refills where applicable.
8. The prescriber will need to manually sign the form, ensuring compliance with the requirement for a handwritten signature. Confirm the date of the signature is also included.
9. Once all fields are completed, review the form for any errors or missing information, then save your changes. You can choose to download, print, or share the completed form as needed.

Complete your RxCrossroads Referral Form For DEPOT online today!